Abdominal Trauma is the main cause of morbidity and mortality worldwide and is still one of the most frequent causes of death in the first four decades of life. Moreover, it remains a major public health problem among all countries, regardless of the socioeconomic status [1].

The solid organs such as spleen, liver, kidney, pancreas, etc., are the most vulnerable. In solid organ injury some studies found liver to be the most common injured organ followed by spleen and kidney [2,3]. However, some other studies have reported spleen to be most common injured abdominal organ [4,5]. Pancreatic injuries secondary to trauma are uncommon and often result from high energy mechanisms of injury to the trunk.

These organs protected by bones and located deep in abdomen. The principal complication which causes death injuries of the parenchymatous organ is hemorrhage in abdominal cavity. So, the outstanding features of injury to solid organ are the haemorrhage and shock. The predominant source of morbidity and mortality are bleeding and visceral perforation associated with sepsis [4,6].

In setting of blunt trauma solid organs often sustain contusion or laceration, causing bleeding that may require surgical management. Deceleration forces cause linear shearing and stretching between relatively free and fixed objects. As bowel loop travel from their mesenteric attachments, tear and vascular injury of mesentery can occur. Greater the number of solid organs injured, greater are chances of small bowel and mesenteric injury. Bowel and mesentery are involved in 1/3rd cases of pancreatic and solid organ injury [4].

Despite injuries being one of the leading causes of morbidity and mortality in the developing world, little attention has been given to halt the occurrence of these injuries and the management of the victims. This study was conducted to highlight the trend of Solid Organ Injury among Blunt Trauma Abdomen patients in a tertiary care Hospital.

Aims and Objective

To determine the trend of Solid Organ Injury among Blunt Trauma Abdomen patients in a tertiary care Hospital.

Study Design

Observational prospective study

Study Period

July 2018 to December2019

Study Population

FAST positive patients admitted in study period at ATC PGIMER Chandigarh, India were included in the study as per the inclusion and exclusion criteria. Informed understood written consent was taken from all the patients and approval from the institute’s ethical committee was obtained.

Sample Size

Seventy-five consecutive patients were recruited based on satisfying the inclusion and exclusion criteria. All the recruited patient's injuries were classified according to existing classification of organ injury. Pattern, prevalence, non-operative versus operative management and outcome in term of mortality and morbidity were monitored.

Eligibility

All consecutive patients with blunt trauma abdomen admitted during the time Frame of the study.

Inclusion Criteria

• All patients with blunt trauma abdomen having Fast Positive or evidence of solid or viscous injury clinically or radiologically

• Both Sex

• Age >14 years and <80 years

• Patients giving a valid informed consent

Exclusion Criteria

• Age <14 years as they are managed by department of pediatric surgery at PGIMER Chandigarh

• Patients who refuse to give consent

• Patients having GCS score less than or equal to 4 on arrival

Material and Methods

Advance Trauma Center PGIMER Chandigarh is the major trauma center of India and it caters major population of Punjab, Haryana, Chandigarh, Himachal, Uttar Pradesh, Bihar, JandK, Rajasthan and act as referral center for the urban and rural hospitals within the region. It has a computerized registry into which trained data collectors have prospectively entered data on all injury admissions. Patients admitted for Blunt Trauma Abdomen were taken into study and categorized into:

• Patients with hollow viscous perforation

• Patients with solid organ injury

• Patients with solid and hollow viscous organ injury along with other coexisting injuries

Patients were managed as per existing protocol of trauma guidelines of the institute and ATLS guidelines and outcome in term of morbidity mortality and length of hospital stay was monitored. Operative, non-operative management and its indications and outcomes were evaluated.

Clinical Course

Patients with blunt trauma abdomen were taken and their history was taken. Name, age, sex, residence, mode of injury, time of injury, time of arrival at ATC, brief history about antecedent incident was taken. Primary survey was done and GCS of patient and vitals such as pulse, blood pressure, respiration was noted. Airway, breathing, circulation was secured as per ATLS guidelines. Secondary survey was done and detailed injuries were noted from head to toe.

After initial resuscitation patient underwent routine blood investigations such ABG, haemogram, blood biochemistry including electrolytes, renal function test and liver function test. Medico legal x-rays of skull with cervical spine, bilateral hip with pelvis, chest and abdominal X-ray was performed in addition injury specific x rays. FAST was done preliminary for BTA. In FAST positive patients CECT abdomen was performed and details of organ injured was noted. All the injuries noted clinically and by radiology were given an AIS and ISS score. Specific organ injuries were graded according to AAST grading of organ injuries.

Conservative or surgical management was done as per existing guidelines of institute. Conservative management includes BTA charting (hourly monitoring of pulse, blood pressure, respiration rate, urine output, abdominal girth, febrile status, 6hourly hemogram) transfusion of blood products, radiological interventions like percutaneous drainage or angioembolization, as guided by the clinical status of the patient, biochemical and radiological findings.

Surgical management for hollow viscus perforation and hemodynamicaly unstable solid organ injury includes exploratory laprotomy. Postoperatively, patient was monitored and managed according to clinical features, hemodynamic status with the help of biochemical and radiological investigations as indicated. Mortality and morbidity were noted.

Statistical Analysis

Data were summarized and expressed as frequency and percentages. All calculations were conducted with standard statistical programs (SPSS 8.01, SPSS, Inc, Chicago IL).

Observations and Results

Seventy-five patients admitted to Trauma center during study period were selected for the study based on inclusion and exclusion criteria. Following observations were made based on their admission and their stay and management. There were 75 patients who were included in this study belonged to the age group 16-75 years. The most common age group affected was 16-30 years which constitute 56% of total affected population. 61-75 years group constituted least affected group (Table 1).

Table 1: Age and Gender Distribution in Blunt Trauma Abdomen Patients

Table 2: Solid Organ Injury in Blunt Trauma Abdomen Patients

Table 3: Pattern of Solid Organ Injury

Table 4: Grades of Solid Organ Injury

In the present study, Solid Organ injured in 54(72%) of cases, out of total 75 cases (Table 2) (Figure 2).

Liver (40% n=30) followed by spleen 28(37.33%) are the most common organ injured in case of blunt trauma abdomen. Kidney was third 7(9.33%) and Pancreas was found to be 4th solid organ injured in case of blunt trauma abdomen.

Figure 1: Age and Gender Distribution in Blunt Trauma Abdomen Patients

Figure 2: Solid Organ Injury in Blunt Trauma Abdomen Patients

Figure 3: Pattern of Solid Organ Injury

Urinary bladder injuries and retroperitoneal hematoma were found to be relatively uncommon and both constituted 5.33% of total blunt trauma abdominal injuries (Table 3) (Figure 3).

Frequency of Grade II and grade III liver was higher in case of liver injury (28%) of total blunt trauma abdomen cases. Higher grade i.e. grades III and grade IV injuries (12.9%) were found to be more in kidney contrast to liver injuries. Grade I and II kidney injury constitute 2.6% of organs injured in blunt trauma abdomen. Most of the bladder injuries (4%) were of grade II. Among the pancreatic injuries, 2.6% were grade I and grade II injuries, 2.7% were grade III injuries and 2.6% were grade of IV and V grade. Zone II hematoma (4%) were found to be more common than zone I (1.3%). No zone III of retroperitoneal hematoma was found in this study. (Table 4 and Figure 4).

Figure 4: Grades of Solid Organ Injury

Blunt trauma to abdomen is critical component for mortality and morbidity, forming an essential component of the initial evaluation of a poly-trauma patient. 

Out of 75 patients of blunt trauma abdomen 56 patients were of solid organ injury. Among all solid organs involved liver was most common in total 30 patients (53%) similar to studies conducted by Arumugam et al [7], where liver injury is 36% and 34% by Solanki et al [8].

In the study done by M J George et al [9], Liver was most commonly involved organ (40.9%) followed by spleen (23.64%). This can be explained as the liver occupies the largest area in abdominal cavity.

In our study grade 2 liver injuries were most common with the incidence of 14.7%. Grade 3 liver injuries were present in 13.4% and grade 4 liver injuries were present in 8% of blunt trauma abdomen cases. Chien et al [10], in a retrospective study found the incidence of grade 1 liver injury 25.1%, grade 2 liver injury 26%, grade 3 liver injuries 24% and grade 4 liver injuries 6.4%.

In our study 28 patients (37.33% of cases) had splenic injury and was second most common solid organ injured in blunt trauma abdomen. This was in contrast to study by Costa et al [11], where spleen was most common organ injured. In this study splenic injuries grade 3 (14.5%) were common. Even for high grade splenic injuries NOM was excellent modality for management with no mortality. One patient of grade IV spleen injury (out of total 9 cases of grade IV splenic injury) underwent spleenectomy. There was no mortality in patients of splenic injury. The management was again in contrast to study conducted by Costa et al 11in which 22 out of 36 patients were treated surgically and mortality was 30.5%.

Injury to kidneys was found in 7 patients (9.3 %) of cases in our study and pancreatic injuries were found in 6 patients (8%) of cases. One patient of grade IV pancreatic injury underwent nasojejunal tube placement and one patient of grade V pancreatic injury underwent ERCP and stent procedure.

Solid organs such as liver, spleen, kidney, pancreas, etc., are the most vulnerable and are more likely to be involved in case of Solid Organ Injury among Blunt Trauma Abdomen patients. Improved motor vehicle safety; rapid emergency transport; and rapid intervention should help to reduce the mortality and morbidity associated with this public health problem.

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