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BLUNT ABDOMINAL TRAUMA IN HEAD INJURIES
793 these dates, were due in part to fluctuations in the incidence of anencephalus, cephalocele, and spina bifida (fig. 2). In Scotland, where the stillbirth-rate continued to fall in 1950-57,6 the annual reports of the Registrar General indicate that during these years the incidence of anencephalic stillbirths increased much less than in Birmingham (figs. 1 and 3). Reliable figures for cephalocele and spina bifida are not available for Scotland, since hydrocephalus is often the cause of death certified in these cases. The suggestion by Richards and Lowe1 that the failure of the stillbirth-rate for England and Wales to decline in 1949-57 was largely the fault of the maternity services is difficult to reconcile with this evidence that part at least of the arrest and later resumption of the decline was due to influences which can affect the incidence of neuraltube defects. These defects are established some weeks before most women receive antenatal care, and if poor care had any effect it would probably be to reduce incidence at birth, by increasing the abortion-rate among those affected. Not enough is known about the setiology of neural-tube defects to suggest other possible reasons for the fluctuations shown in fig. 1. Anencephalus, which has been more closely studied than the other defects, is known to vary in incidence according to ethnic group, social class, maternal age and parity, and season of conception; but the available evidence does not suggest that the distribution of the population in respect of any of these influences has undergone the extremely sharp variations, first in one direction and then in the other, that would be needed to account for the changes in incidence observed. MacMahon et al.2 showed that the decline between 1941 and 1949 was not due to a change in the birth-rank distribution, and Recordreported that the rise in the incidence of anencephalus in Scotland between 1949 and 1958 (fig. 3) was independent of social class, maternal age and parity, and season of birth. There is, however, some evidence of an interaction between variables in the data on seasonal incidence presented by Leck and Record.8 These data show that the high rates of anencephalus observed in Birmingham in 1954-59 and in Scotland in 1958-61 can be attributed mainly to increases in incidence among summer births, although before these dates the summer-rate was relatively low even in years when the total incidence was high. It therefore seems likely that the high rates seen in 1940-45 differed in xtiology from those observed more recently. In conclusion, it should be noted that although the primary concern of this paper is with neural-tube defects as causes of prenatal death, the data in the table may also be used to estimate the extent of the increase in the proportion of children with spina bifida or cephalocele who survive (often with incurable handicaps). Assuming that there were no deaths among infants who left the city, only 16% of children with these defects born in 1950-51 survived through infancy; but infant survival has improved in every subsequent two-year period (notably from 18% in 1954-55 to 24% in 1956-57, and from 26% in 1960-61 to 39% in 1962-63), and 44% of those born in 1964-65 (excluding births within a year of the survey) were alive one year later. SUMMARY
After declining between 1940 and 1949, the incidence of anencephalus in Birmingham rose to a peak in 1956-57, 6. 7. 8.
Lancet, 1966, i, 1197. Record, R. G. Br. J. prev. soc. Med. 1961, 15, Leck, I., Record, R. G. ibid. 1966, 20, 67.
93.
and has since fallen again. The rate for spina bifida aperta and cephalocele exhibited parallel fluctuations. The decline in the stillbirth-rate before 1950 and after 1957, and its arrest between these dates, were due in part to these fluctuations. The combined stillbirth and infant-death rate among children with spina bifida or cephalocele fell from 84% in 1950-51 to 56% in 1964-65. For access to the above data I thank Dr. E. L. M. Millar (medical officer of health, Birmingham) and his staff, and the medical staff and statistical and records officers of local hospitals. I also thank Mrs. Eileen Armstrong, Miss Gillian Davis, Miss Ida Giles, Miss Denise Kinch, and Mrs. Betty Mann, for their help in assembling the data. The work was assisted by a grant from the Association for the Aid of Crippled Children, New York.
BLUNT ABDOMINAL TRAUMA IN HEAD INJURIES RICHARD NICHOLSON M.R.C.S. SENIOR HOUSE-OFFICER
GERALD GOLDEN Lond., F.R.C.S.
M.B.
CONSULTANT SURGEON, ORTHOPÆDIC AND ACCIDENT DEPARTMENTS
ROYAL SURREY COUNTY
HOSPITAL, GUILDFORD,
SURREY
THE combination of head injuries and chest injuries is hazardous1 2; almost as hazardous is the association of head injuries and blunt abdominal trauma. We describe here the case-reports of 12 patients with injuries to the head and abdomen who were admitted to the Royal Surrey County Hospital between February, 1964, and July, 1965. CASE-REPORTS
The patients had all sustained head injuries of varying grades of severity, and had all had concussion at the time of the accident. The salient features are summarised in the accompanying table. DIAGNOSIS
The findings in this short series suggest that when there are abdominal as well as intracranial injuries, the greater the degree of unconsciousness, the less is the chance of survival. One reason for this is that unconsciousness usually indicates more severe trauma. Another is that unconsciousness due to acute oligaemia may be wrongly attributed to brain injury. A third is that, when an unconscious patient has an abdominal injury, there may be little or no evidence of it. What signs of intra-abdominal haemorrhage should be looked for ? Bruising of the abdominal wall can be seen. Guarding is demonstrable only in the lightly unconscious patient, if at all. The " doughy feel " of the abdomen mentioned in some textbooks is difficult to elicit unless a considerable amount of blood has accumulated; the sign is helpful only at a late stage. The fact that bowel sounds were heard in 7 patients who had a good deal of blood in the peritoneal cavity accords with the finding of Rob3 that sounds are not abolished by haemoperitoneum. Increasing distension, found on repeated measurement of the abdominal girth, is sometimes an aid. A fall in arterial blood-pressure, unexplained by injuries to the chest or limbs, is often the only pointer to intra-abdominal haemorrhage. 4-6 In several of our patients, 1. 2. 3. 4. 5. 6.
Berry, F. Milit. Surg. 1953, 113, 448. Schrire, T. S. Afr. med. J. 1963, 37, 750. Rob, C. G. Cited in Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery; p. 518. Bristol, 1960. Grise, R. F. Ky med. J. 1960, 58, 473. Perry, J. F. Minn. Med. 1964, 47, 518. Illingworth, G., Jennett, W. B. Lancet, 1965, ii, 515.
794 BLUNT ABDOMINAL TRAUMA IN HEAD
intra-abdominal haemorrhage was diagnosed, and in others it should have been diagnosed by exclusion of other more obvious causes of a falling blood-pressure. Where there is doubt, laparotomy with adequate transfusion is fully justifiable. This might have saved patients, 7, 8, and 10. Other aids to the diagnosis of intraperitoneal haemorrhage are few. The absence of psoas shadows may be demonstrable on a straight abdominal film. There are references in published American and French reports to the peritoneal tap; though we have no experience of this method, we think it should be given a trial in a doubtful case. Drapanas and McDonald and Whiffen suggest that the investigation can be made reasonably safe and that it is accurate in about 85% of cases. In these grave situations, a small additional risk is acceptable if it leads These workers remark that a positive to a firm finding is reliable, though a negative one is not.
diagnosis.
MANAGEMENT
In 7 of the 8 fatal cases, necropsy disclosed extensive 7. 8.
Drapanas, T., McDonald, J. Surgery, 1961, 50, Whiffen, J. D. Clin. Med. 1964, 71, 39.
742.
INJURIES
haemorrhage, and in some the viscera were very pale. Looking back, we believe that several patients were insufficiently transfused, notably patients 4 and 7. Blood potent weapons, and it is not push young patient into failure. Measurement of central venous pressure is probably the best and most easily verifiable indication of the level of the bloodvolume. Ordinarily, shock must be treated before laparotomy is undertaken; but there are some patients remains
one
easy to
of
our most
a
(such as patient 11) in whom resuscitation and laparotomy simultaneously.9
must go on
SUMMARY
In the presence of head injuries-particularly when the patient is unconscious-blunt abdominal trauma may go unrecognised. Intra-abdominal haemorrhage, which may rapidly prove fatal, will sometimes be revealed by clinical examination and especially by an unexplained fall in arterial blood-pressure. Early laparotomy, preceded or accompanied by adequate blood-transfusion, often gives the patient his only chance of survival.
repeated
9.
Campbell, R. Bull. post Grad. Comm. Med. Univ. Sydney, 1962, 17, 258.
After declining between 1940 and 1949, the incidence of anencephalus in Birmingham rose to a peak in 1956-57, 6. 7. 8.
Lancet, 1966, i, 1197. Record, R. G. Br. J. prev. soc. Med. 1961, 15, Leck, I., Record, R. G. ibid. 1966, 20, 67.
93.
and has since fallen again. The rate for spina bifida aperta and cephalocele exhibited parallel fluctuations. The decline in the stillbirth-rate before 1950 and after 1957, and its arrest between these dates, were due in part to these fluctuations. The combined stillbirth and infant-death rate among children with spina bifida or cephalocele fell from 84% in 1950-51 to 56% in 1964-65. For access to the above data I thank Dr. E. L. M. Millar (medical officer of health, Birmingham) and his staff, and the medical staff and statistical and records officers of local hospitals. I also thank Mrs. Eileen Armstrong, Miss Gillian Davis, Miss Ida Giles, Miss Denise Kinch, and Mrs. Betty Mann, for their help in assembling the data. The work was assisted by a grant from the Association for the Aid of Crippled Children, New York.
BLUNT ABDOMINAL TRAUMA IN HEAD INJURIES RICHARD NICHOLSON M.R.C.S. SENIOR HOUSE-OFFICER
GERALD GOLDEN Lond., F.R.C.S.
M.B.
CONSULTANT SURGEON, ORTHOPÆDIC AND ACCIDENT DEPARTMENTS
ROYAL SURREY COUNTY
HOSPITAL, GUILDFORD,
SURREY
THE combination of head injuries and chest injuries is hazardous1 2; almost as hazardous is the association of head injuries and blunt abdominal trauma. We describe here the case-reports of 12 patients with injuries to the head and abdomen who were admitted to the Royal Surrey County Hospital between February, 1964, and July, 1965. CASE-REPORTS
The patients had all sustained head injuries of varying grades of severity, and had all had concussion at the time of the accident. The salient features are summarised in the accompanying table. DIAGNOSIS
The findings in this short series suggest that when there are abdominal as well as intracranial injuries, the greater the degree of unconsciousness, the less is the chance of survival. One reason for this is that unconsciousness usually indicates more severe trauma. Another is that unconsciousness due to acute oligaemia may be wrongly attributed to brain injury. A third is that, when an unconscious patient has an abdominal injury, there may be little or no evidence of it. What signs of intra-abdominal haemorrhage should be looked for ? Bruising of the abdominal wall can be seen. Guarding is demonstrable only in the lightly unconscious patient, if at all. The " doughy feel " of the abdomen mentioned in some textbooks is difficult to elicit unless a considerable amount of blood has accumulated; the sign is helpful only at a late stage. The fact that bowel sounds were heard in 7 patients who had a good deal of blood in the peritoneal cavity accords with the finding of Rob3 that sounds are not abolished by haemoperitoneum. Increasing distension, found on repeated measurement of the abdominal girth, is sometimes an aid. A fall in arterial blood-pressure, unexplained by injuries to the chest or limbs, is often the only pointer to intra-abdominal haemorrhage. 4-6 In several of our patients, 1. 2. 3. 4. 5. 6.
Berry, F. Milit. Surg. 1953, 113, 448. Schrire, T. S. Afr. med. J. 1963, 37, 750. Rob, C. G. Cited in Hamilton Bailey’s Demonstrations of Physical Signs in Clinical Surgery; p. 518. Bristol, 1960. Grise, R. F. Ky med. J. 1960, 58, 473. Perry, J. F. Minn. Med. 1964, 47, 518. Illingworth, G., Jennett, W. B. Lancet, 1965, ii, 515.
794 BLUNT ABDOMINAL TRAUMA IN HEAD
intra-abdominal haemorrhage was diagnosed, and in others it should have been diagnosed by exclusion of other more obvious causes of a falling blood-pressure. Where there is doubt, laparotomy with adequate transfusion is fully justifiable. This might have saved patients, 7, 8, and 10. Other aids to the diagnosis of intraperitoneal haemorrhage are few. The absence of psoas shadows may be demonstrable on a straight abdominal film. There are references in published American and French reports to the peritoneal tap; though we have no experience of this method, we think it should be given a trial in a doubtful case. Drapanas and McDonald and Whiffen suggest that the investigation can be made reasonably safe and that it is accurate in about 85% of cases. In these grave situations, a small additional risk is acceptable if it leads These workers remark that a positive to a firm finding is reliable, though a negative one is not.
diagnosis.
MANAGEMENT
In 7 of the 8 fatal cases, necropsy disclosed extensive 7. 8.
Drapanas, T., McDonald, J. Surgery, 1961, 50, Whiffen, J. D. Clin. Med. 1964, 71, 39.
742.
INJURIES
haemorrhage, and in some the viscera were very pale. Looking back, we believe that several patients were insufficiently transfused, notably patients 4 and 7. Blood potent weapons, and it is not push young patient into failure. Measurement of central venous pressure is probably the best and most easily verifiable indication of the level of the bloodvolume. Ordinarily, shock must be treated before laparotomy is undertaken; but there are some patients remains
one
easy to
of
our most
a
(such as patient 11) in whom resuscitation and laparotomy simultaneously.9
must go on
SUMMARY
In the presence of head injuries-particularly when the patient is unconscious-blunt abdominal trauma may go unrecognised. Intra-abdominal haemorrhage, which may rapidly prove fatal, will sometimes be revealed by clinical examination and especially by an unexplained fall in arterial blood-pressure. Early laparotomy, preceded or accompanied by adequate blood-transfusion, often gives the patient his only chance of survival.
repeated
9.
Campbell, R. Bull. post Grad. Comm. Med. Univ. Sydney, 1962, 17, 258.