Experience in diagnosis and treatment of 119 patients with traumatic visceral rupture

Abstract

AIM: To summarize our experience in diagnosis and treatment of 119 patients with traumatic visceral rupture.

METHODS: One-hundred-and-twenty-two patients (21 women and 101 men, with an average age of 44.75 years) were studied. The causes of injury included bullet wound, stabbing wound, falling from building, traffic accident, etc. First, more than 2 intravenous transfusion pathways were set up immediately, and pre-operative preparations were made as quickly as possible. The patient was put immediately under monitoring in the ICU. Then, emergency explorative surgery was carried out to stop the bleeding and repair the ruptured viscera. In 20 patients with severe illness, the combined therapy of “Four High Doses in Large Volume and One Support” (FHDOS) was used, consisting of a short delivery period of high doses of anisodaminum in large volumes, a short delivery period of high doses of dexamethosone in large volumes, high doses of antibiotics in large volumes, high doses of abdominal cavity washing liquid in large volumes, and one nutritional support.

RESULTS: One-hundred-and-nineteen patients recovered after the active treatment and 3 patients died. The mortality rate was 2.5%.

CONCLUSION: Diagnosis and treatment should be quick, decisive, correct and rational. It is imperative to keep the respiratory tract unobstructed and to treat shock. Abdominal explorative surgery should be carried out to stop bleeding and repair ruptured viscera simultaneously. Efforts should be made to avoid misdiagnosis and ICU monitoring provides significant benefit to the patient. The new treatment method of FHDOS is simple, practical and effective for critically ill patients, and it plays a key role in treating multiple organ failure.

Key Words: Traumatic visceral rupture/diagnosis, Shock, Traumatic visceral rupture/therapy

INTRODUCTION

Visceral rupture following trauma is one of the most common acute abdominal illnesses encountered in general surgery, with most patients being in a complicated and critical condition and near death. Therefore, it is necessary to choose a simple and reliable method of examination that will be completed in a short period of time and provide a clear diagnosis; it is also necessary to choose the optimum time for surgery and to apply a rational operative approach as well as the right postoperative measures for recovery. The following is a report on the diagnosis and treatment of 122 patients with visceral rupture following trauma that were treated in our department over the past 10 years. Of these patients, 119 were cured by the treatment and 3 died. The mortality rate was 2.5%.

MATERIALS AND METHODS

Patients

The patient population included 99 men and 20 women, ranging in age from 42 years-old to 75 years-old. The causes of injury included bullet wound, stabbing wound, falling from building, traffic accident, etc. The cases of ruptured viscera involved liver (n = 21), spleen (n = 50), small intestine (n = 19), colon (n = 9), stomach (n = 10), duodenum (n = 3), pancreas (n = 7), and multiple organs (n = 51).

For the operation time and anesthetic methods used, 79 patients were operated upon within 30 min of the cause of injury, 29 between 30 min and 3 h, and 11 patients at 3 h later. Fifty-nine patients were treated under general anesthesia with trachea incubation, and all others were treated under epidural anesthesia.

For the complications, 3 patients developed infection at the incision site, 1 patient had an intestinal obstruction, 1 patient experienced a disruption at the incision site, and 1 patient had multiple intraperitoneal abscesses.

Methods

In each case, we first opened at least two intravenous passages immediately, one of which was in the upper limb. Preoperative preparations were made quickly, while the patients were under ICU monitoring[1]. The emergency abdominal explorative surgery was performed with the primary aims of stopping the bleeding and repairing the ruptured viscera.

For patients classified as being in very severe condition, especially those with multiple organ dysfunction (MOD), we applied the combined therapy of “four high doses in large volume and one support” (FHDOS). This treatment was carried out as follows. First, a short period of high dose anisodaminum was delivered in large volumes as an intravenous injection of 40 mg once, followed by another 40 mg at 30 min later according to patient′s condition; the total amount was allowed to reach 120-240 mg a day or 40 mg by intravenous injection every 15 min until the patient′s condition was under control. Second, a short period of high dose dexamethasone was delivered in large volumes as an intravenous injection of 100-200 mg once, followed by similar or decreasing doses every day for 1-3 d accordingly. Third, high doses of antibiotics were delivered in a large volume; we selected and used antibiotics according to the clinical condition and the type of possible bacterial pathogens, which was then adjusted according to the drug sensitivity tests for the bacteria. In addition, we always paid attention to the prevention and treatment of dual or mixed infections. Fourth, high doses of abdominal cavity washing liquid were delivered in large volume; in general, we cleaned the abdominal cavity with 6000-8000 mL of normal saline. Fifth, the “one support” portion of the treatment was applied as full nutritional support (TPN and TEN)[2].

RESULTS

One-hundred-and-nineteen patients were cured successfully, and 3 patients died. The mortality rate was 2.5%.

DISCUSSION

In this study group, 92 patients (77.3%) were in shock on admission. Abdominal punctures were carried out in 94 of the patients (97.9%) and positive results were obtained for 92. Of the 81 patients who underwent B-ultrasound examination, 79 showed positive results.

Conditions of such patients are usually desperate and critical. The following emergency management procedures should be organized and applied with all-out effort of the critical care team. First, the surgeon should immediately open more than 2 venous passages, one of which should be in the upper limb. Second, the team should make pre-operative preparations as quickly as possible and immediately put the patients under ICU monitoring. Third, an emergency explorative laparotomy should be conducted to stop bleeding and repair the ruptured viscera. Fourth, for patients with co-existing craniocerebral injury (such as the 9 in our study), the emergency abdominal explorative surgery should be carried out first. However, it is necessary to simultaneously open the cranium for decompression and evacuation of intracranial hematoma, if present. Fifth, bleeding from a rupture of the large intracelial or external blood vessels and viscera rupture endangers the patient′s life most; the amount of this type of bleeding in the 39 patients in our study was 2000 mL to 5100 mL.

ICU monitoring is of significance for patients suffering from viscera rupture with mixed injuries.

Ruptures of the gastrointestinal tract occurred in 42 patients in our study population. Intra-abdominal infection and surgical wound infection should be prevented by washing with a large volume of saline.

In summary, the diagnosis and treatment of these cases should be quick, decisive, correct and rational. It is necessary to keep the respiratory tract unobstructed and to combat shock while simultaneously performing abdominal explorative surgery to stop the bleeding and repair the ruptured viscera. It is critical to avoid misdiagnosis, and patients in critical condition will benefit from ICU monitoring and treatment by FHDOS[3]. Ultimately, by intensifying the level care and correcting the shock condition, it is possible to prevent and rationally treat complications and life-threatening multiple organ failure.