Options in the management of solid visceral injuries from blunt abdominal trauma

Non-operative management of solid visceral injuries from blunt abdominal trauma, especially in stable patients, has become the order of the day in developed countries. However, the safety and feasibility of such an approach in the absence of modern amenities like CT, angiography and ICU support has remained a point of controversy. This prospective study analyzes the manifestations, management and outcome of solid visceral injuries in 72 patients with blunt abdominal trauma, relying solely on readily available diagnostic modalities, viz. abdominal X-ray, ultrasonography and paracentesis, in the setting of a hospital lacking CT and ICU support. Road traffic accident was the most common mechanism of blunt abdominal trauma in our study, most victims being males in the third decade of life. Chest injury was the predominant associated injury (26%), but head injury was the most common extra-abdominal injury causing death. Plain abdominal X-ray accurately diagnosed all 3 cases of intestinal injury. Abdominal ultrasonography had a sensitivity of 89%, specificity of 100%, and accuracy of 100% in diagnosing abdominal solid visceral injuries. The sensitivity, specificity and accuracy of diagnostic paracentesis in detecting hemoperitoneum, were 82%, 86% and 90% respectively. 39% patients were ultimately subjected to laparotomy. Frequency of solid visceral injuries encountered were: liver 47.9%, spleen 29.2%, kidneys 14.6% and pancreas 8.3%. Organ salvage was possible in 90.3% of operated cases. Postoperative morbidity was 26%, mostly due to chest and wound infections. Non-operative morbidity rate was 20% with failure of non-operative management occurring in 10% cases. The overall mortality was 21%. All deaths in the non--operative group (mortality 9%) were due to associated head injury, whereas deaths in the operative group (14% mortality) were a consequence of the abdominal trauma and/or surgery. The average number of blood transfusions received by patients in the non-operative and operative groups were 0.5 and 3.0 respectively. The average duration of hospital stay was 7.8 days for the non-operative group and 10.4 days for the operative group. Thus, a multipronged approach employing abdominal X-ray, ultrasonography and diagnostic paracentesis, correlated with clinical findings, can be fairly useful and accurate in early diagnosis and management of solid visceral injuries from blunt abdominal trauma at a limited-resource set-up lacking CT and ICU support, with acceptable morbidity and mortality.