Closed abdominal injuries are one of the most common clinical emergencies, especially in today’s world where traffic accidents remain high. Closed abdominal injuries are often urgent and complex, and many patients have life-threatening conditions that require urgent resuscitation. Moreover, many casualties do not have obvious abdominal wounds and often combine compound injuries, which are easily misdiagnosed and missed. From January 2005 to January 2010, 121 cases of closed abdominal injuries caused by car accidents were admitted to our hospital, and the experience of their treatment is reported as follows.
I. Clinical data
1.General information
There were 89 male cases and 32 female cases in this group, with ages ranging from l1 to 76 years old and a median age of 37.3 years old.
2, injury site classification
There were 72 cases of single organ injury in the abdominal cavity, 49 cases of multiple organ injury in the abdominal cavity, 38 cases of other important system injuries such as cranial, thoracic, urological and orthopedic injuries, and 87 cases of combined hemorrhagic shock. There were 72 cases of splenic rupture, 35 cases of liver rupture, 32 cases of intestinal rupture (including large and small intestine and rectum), 7 cases of gastric rupture, 25 cases of renal contusion, 35 cases of retroperitoneal hematoma, and 46 cases of mesenteric contusion. There were 25 cases of combined craniocerebral injury, 32 cases of fracture, and 12 cases of hemopneumothorax.
3.Treatment situation
There were 109 cases of emergency surgery, 7 cases of delayed surgery, and 5 cases of non-surgical treatment. There were 66 cases of splenectomy, 6 cases of spleen repair, 35 cases of liver repair, 9 cases of partial hepatectomy, 29 cases of intestinal rupture repair, 10 cases of small intestinal fistula, and 10 cases of small intestinal fistula. There were 10 cases of enterostomy, 15 cases of resection and anastomosis of damaged small intestine, 7 cases of gastric rupture repair. The rupture of mesentery was repaired in 21 cases. There were 10 cases of laparoscopic surgery (5 cases of gastric repair, 2 cases of small bowel repair, and 3 cases of laparoscopy). Damage control surgery was performed in 5 cases.
4, the group cured 112 cases, accounting for 92.6% (112/121); mortality rate of 7.4% (9/121).
Cause of death: 5 cases of hemorrhagic shock, 4 cases of acute multi-organ failure, and 4 cases of combined severe cranio-cerebral injury.
II. Discussion
1. Pre-hospital treatment
The success of the treatment of closed abdominal injuries is largely related to the timely and accurate on-site first aid. Timely and appropriate evacuation is closely related. Do your best to shorten the time after the injury to the hospital emergency, especially in the case of batches of casualties. The first is to evacuate the sick and wounded from the accident site in a timely and rapid manner. And accurately implement emergency treatment measures at the scene. Including the establishment of intravenous access. If there are compound injuries, perform cardiopulmonary resuscitation and tracheal intubation if necessary. Our hospital has established a linkage with the local highway management station and has specially assigned doctors and ambulances to be stationed at highway intersections so that they can be dispatched as soon as the situation occurs. However, there are still some casualties who died on the spot or were already dead when they arrived at the hospital.
2. In-hospital treatment
Firstly, the early treatment of shock is emphasized in the emergency room, and effective fluid access is established in time, including deep vein placement, rapid infusion, rapid restoration of effective blood circulation, and creation of conditions for emergency surgery. In case of emergency, the necessary examination and disposal are carried out and then sent directly to the operating room for surgery. We send the casualty directly to the operating room for resuscitation when we find that rapid fluid infusion cannot correct shock after sending him to the emergency room. The rehydration fluid is mainly crystalloid and alternated with colloid fluid to restore tissue perfusion and improve tissue hypoxia as quickly as possible. If necessary, whole blood can be transfused to correct shock. The 87 cases in this group had different degrees of hemorrhagic shock when they came to the hospital, and after active anti-shock treatment, most of them won the time for surgical treatment.
3.Decisive caesarean section
For those who cannot be corrected by active anti-shock treatment and have clear or high suspicion of ruptured visceral injury, dissection should be performed decisively. Whether to receive surgical treatment after the injury directly affects the cure rate in a timely manner.
We have learned that the indications for dissection are.
(1) Progressive increase in abdominal pain and peritoneal irritation signs.
(2) abdominal puncture to extract gas, non-coagulated blood, bile or gastrointestinal contents
(3) The presence of free gas under the diaphragm.
(4) Ultrasound and CT suggesting accumulation of blood in the abdominal cavity.
(5) Low or progressive decline in hemoglobin.
(6) dynamic observation of abdominal symptoms and signs without improvement or aggravation
(7) Those with gastrointestinal bleeding.
(8) Shock that is difficult to explain with other injuries.
The principle of surgical exploration: first stop bleeding, pay attention to repair, and strictly grasp the indications for removal of injured organs as the principle. Intraoperative investigation should be carefully and carefully, so as not to miss the injury organs and bleeding parts.
4.Composite injury treatment
When closed abdominal injuries are accompanied by multiple organ injuries, the corresponding treatment should be given according to the location, severity and urgency of the injury, and in principle, priority should be given to the life-threatening injuries. For compound injuries should ask for multidisciplinary consultation and treatment together.
According to the principles of first aid treatment:
(1) preliminary judgment of the injury, clear treatment order, distinguish the priority, priority treatment of life-threatening injuries;
(2) Cranial, cerebral, thoracic and abdominal injuries are the focus of treatment;
(3) Identification and treatment of life-threatening injuries, such as airway obstruction, tension pneumothorax, open pneumothorax, etc;
(4) Resuscitation of shock, control of obvious external bleeding and release of intracranial hypertension that may lead to brain herniation.
After emergency treatment, immediately send to the operating room for life-saving surgery.
5.Injury control surgery
With the increased awareness of the injury characteristics of trauma patients, damage control surgery (DCS) is being used more and more widely. Patients in car accidents often have multiple injuries involving multiple parts and require multidisciplinary joint treatment, thus the clinical treatment is difficult and the emergency operation time is long, so the strategy of DCS should be used as a priority. the reasonable application of DCS can effectively reduce the morbidity and mortality rate of complex trauma patients. Due to the influence of many factors such as technical conditions, the application of DCS should be fully considered in the process of treating severe multiple injuries in the grass-roots hospitals. due to the complex injuries, the time of post-injury discovery and transportation to hospitals varies, the conditions such as hemorrhagic or traumatic shock are not corrected in time, and the physiological potential of the body is sometimes on the verge of depletion, manifesting as the triad of intractable hypothermia, metabolic acidosis and coagulation dysfunction. This kind of casualty cannot tolerate conventional definitive surgical treatment, and if complete surgery is performed in an emergency, it will cause a fatal second blow to the patient, further aggravate the disorder of the internal environment, which is not conducive to the patient’s safe passage through the acute reaction period or even lead to death. For the management of abdominal injury, the initial management of abdominal injury is mainly to control active bleeding, contamination and temporary closure of the abdominal cavity. Quickly open the abdomen, ligate the blood vessels, perform liver repair or splenectomy, gauze tamponade to stop bleeding if repair is difficult, and perform quick repair of intestinal rupture, ligation of severed ends and placement of drainage. Rapid closure of the abdominal cavity can be performed with simple sutures, artificial biomaterial coverage or even open abdominal cavity. In the five cases of damage control surgery encountered in this group, three cases of extensive contusions of the liver with uncontrollable intraoperative bleeding were closed after ligation of the right hepatic artery and gauze pad caulking; one case combined with severe contusion of the body and tail of the pancreas combined with splenic rupture, the main pancreatic duct was sutured after pancreatic debridement after splenectomy and closed after body and tail caulking; one case of transverse common bile duct combined with duodenal rupture and contusion of the pancreas, external drainage of the common bile duct was performed in one stage In the first stage, external drainage of the common bile duct, duodenal closure, stump fistula and gastrostomy were performed.
6.Rational application of minimally invasive surgery
In recent years, laparoscopic technology has developed rapidly and has gradually become a valuable and promising diagnostic technique in abdominal surgery. In addition, a rapid and targeted whole-body examination is essential to avoid missing injuries in other areas. We have progressively performed some laparoscopic diagnostic treatments, including gastric repair and small bowel repair, according to our own technical conditions. Three of the injured patients suspected of having intra-abdominal organ injuries underwent laparoscopy, and as a result, one of them was found to have a mild contusion on the surface of the right liver, which was treated laparoscopically to stop the bleeding with excellent results and avoid open surgery.