This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citing articles on ISI (4)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Topic Collections  • Gastrointestinal/ Upper Foregut  • Emergency Medicine  • Alert me on articles by topic

Identifying Those Who Are Bleeding

Carlos V. R. Brown, MD; George C. Velmahos, MD, PhD; Angela L. Neville, MD; Peter Rhee, MD, MPH; Ali Salim, MD; Burapat Sangthong, MD; Demetrios Demetriades, MD, PhD

Arch Surg. 2005;140:767-772.

Hypothesis  Despite initial presentation, hemodynamically stable patients with penetrating abdominal trauma may have significant ongoing hemorrhage and major intra-abdominal injuries requiring emergent surgical intervention.

Design  Cohort analytic study.

Setting  Academic, level I trauma center.

Patients  One hundred thirty-nine consecutive hemodynamically stable patients with penetrating abdominal trauma in whom peritonitis was the sole indication for laparotomy.

Main Outcome Measures  The primary outcome was the amount of blood initially found at laparotomy. Secondary outcomes included additional intraoperative blood loss, intraoperative hypotension, transfusion, fluid, and vasopressor requirement; need for admission to the intensive care unit and mechanical ventilation; complications; survivor length of stay in the hospital and intensive care unit; and mortality.

Results  The admission systolic blood pressure (mean ± SD, 131 ± 22 mm Hg) and heart rate (mean ± SD, 91 ± 22 beats/min) were normal. Median time from peritonitis to incision was 40 minutes. Ninety-seven percent of patients had intra-abdominal injury, including 81%, hollow visceral; 36%, solid organ; and 11%, vascular injury. Though most patients had less than 750 mL³ of blood found initially at laparotomy, there were 11% with 750 to 1500 mL³ and 7% with 1500 mL³ or more. Intraoperative hypotension (25%) and blood transfusion (39%) were common. Postoperatively, 40% of patients required intensive care (78% of them requiring mechanical ventilation) and 19% required additional transfusion within 24 hours. Complications occurred in 25% of patients, with intra-abdominal abscess (12%) and wound infection (7%) being the most common. Three patients died, 2 of exsanguination and 1 of multisystem organ failure.

Conclusions  Following penetrating abdominal trauma, peritonitis should be a trigger for emergent operation regardless of vital signs, because hemodynamic "stability" does not reliably exclude significant hemorrhage. Vascular injury, subsequent hypotension, blood transfusion, and complicated postoperative course are common in this population.

Author Affiliations: Department of Surgery, Division of Trauma and Critical Care, University of Southern California Keck School of Medicine, Los Angeles County/University of Southern California Medical Center, Los Angeles (Drs Brown, Neville, Rhee, Salim, Sangthong, and Demetriades); and Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston (Dr Velmahos).