- Email: [email protected]
Diagnosis and management of pancreatic injury
EDITORIALS Diagnosis and Management of Pancreatic Injury Early diagnosis of blunt retroperitoneal pancreatic injury continues to be an enigma. Unwarranted delay in diagnosis and, therefore, in surgical intervention is the single most important factor leading to increased morbidity and mortality. Increased effectiveness in making an early diagnosis depends on: 1) anticipation; 2) recognition of early abdominal findings; 3) appreciation of the low incidence of associated intraperitoneal injuries; and 4) utilization and interpretation of appropriate diagnostic aids. Anticipation: All p a t i e n t s sustaining blunt abdominal injury, such as drivers, passengers, pedestrians, or victims of "stomping," are candidates for retroperitoneal injury. Steering wheel injuries, however, carry the highest risk. The presence of pre-existing pancreatic pathology, such as a pseudocyst, chronic calcific pancreatitis, or a pancreatic neoplasm (reported by Saltzstein and Morales in this issue of Annals), reduces pancreatic compliance to rapid deceleration, thereby increasing the likelihood for contusion or fracture of the gland. Abdominal Findings: Most patients with blunt abdominal trauma present with abdominal tenderness over the area of impact. After intraperitoneal solid organ injury has been ruled out on the basis of no change on vital signs and a negative peritoneal larage, and hollow organ injury has been excluded based on no signs of peritoneal irritation and absence of free pneumoperitoneum, this nonspecific abdominal wall tenderness significantly lessens by two hours and has generally disappeared by six hours. Pain beyond six hours in such a patient is suggestive of retroperitoneal injury and more specifically pancreatic injury. Immediate diagnostic studies, if not yet done, must be initiated. Furthermore any intoxicated patient who complains of abdomirial wall pain or tenderness as sobriety approaches must be suspected of having retroperitoneal injury. Almost all patients with pancreatic injury will have obvious signs of peritoneal irritation by 12 hr to 24 hr after injury. By this time, the likelihood of developing significant morbidity, or even of dying from the injury, has increased significantly. Associated Injuries: Most patients with retroperitonea] pancreatic injury do not have intraperitoneal hollow or solid organ injury. A negative peritoneal lavage or pericentesis and absence of free air, therefore, do not exclude retroperitoneal pancreatic injury. Associated intraperitoneal injuries, when present, lead to earlier laparotomy with incidental identification and therapy for the pancreatic injury. The greater challenge, however, is making an early diagnosm of pancreatic injury in patients without associated intraperitoneal injury.
10:3 (March) 1981
Diagnostic Aids: A progressively rising hypera m y l a s e m i a and increased amylase content in the peritoneal lavage fluid are the most useful diagnostic aids for pancreatic injury. The initial serum amylase level correlates poorly with pancreatic injury, primarily because many patients have been drinking prior to injury. A rising s e r u m a m y l a s e from the time of admission until six hours after injury carries a good correlation. Identification of this correlation and utilizing this change as a meanS fSr making an early diagnosis of pancreatic injury m a n d a t e s the routine obtaining of a serum amylase in all patients presenting to the emergency department with blunt abdominal injury, regardless of etiology. Any patient with a question of abdominal tenderness or guarding extending beyond six hours, in conjunction with a rising serum amylase, warrants immediate preparation for surgical intervention and careful exploration of the retroperitoneal area. Preoperative abdominal and thoracic roentgenographs in patients with pancreatic trauma are often normal in the early post-injury period. Later changes include adynamic ileus due to the retroperitoneal inflammation and sometimes a "ground glass" appearance in the midabdominal area due to lesser sac inflammation and fluid accumulation. Intraoperatively, pancreatic injury must be suspected in any patient with a high retroperitoneal or lesser sac hematoma which may extend into the transverse mesocolon,'as is noted in the Saltzstein-Morales case report. Initial resuscitation of the patient presenting with pancreatic injury is the same as for any patient presenting to the emergency department with blunt injury. Initial restoration of volume depletion is provided by means of balanced electrolyte solution, recognizing that the patient may have a significant depletion in both the plasma volume and the interstitial fluid space volume. Depending on the severity of hypervolemia upon arrival in the emergency department, this restoration of volume depletion can be achieved by way of one, two, or three intravenous routes, with one of these routes serving as a central venous catheter monitor in patients with severe plasma volume depletion. Based on studies published elsewhere, the addition of albumin or plasmanate should not be initiated at this time, as this leads to subsequent problems with pulmonary, cardiac, and renal function. P a r t of the initial resuscitation regimen should include nasogastric decompression in order to remove liquid gastric contents and to remove air in order to decrease the likelihood of vomiting when the patient must subsequently undergo exploratory laparotomy
Ann Emerg Med
172/79
with general anesthesia. Following the initial restoration of plasma volume deficit with balanced electrolyte solution, red cell replacement should be provided when the type and crossmatch has been completed: When the patient is not responding to crystalloid or balanced electrolyte solution replacement in the early post-admission period, type-specific blood should be infused to help m a i n t a i n organ profusion until the period when the type and crossmatch has been completed. Severely volume-depleted patients also require full catheter drainage of the bladder in order to monitor ongoing output as a reflection of restoration of plasma volume and renal blood flow. Anticipating the need for subsequent surgical intervention; antibiotics should be initiated; the specific antibiotics utilized vary from institution to institu-
tion, but have generally included penicillin, clindamycin, and gentamycin at this institution. Antibiotics may be discontinued at the time of laparotomy or approximately three to five days after surgery, depending on the severity of pancreatic injury, the status of associated injuries, and~the extent and type of drainage in the postoperative period. Utilizing this regimen of early diagnosis and resuscitation, the vast majority of patients presenting with pancreatic injury can be successfully resuscitated and returned to their normal environment.
Charles E. Lucas, MD, FACS Professor of Surgery Wayne State University School of Medicine Detroit, Michigan
Emergency Medicine and the Military For those of you ~vho have spent time in the military practicing medicine, you will have no trouble understanding what I am about to describe. The occasion was the first full-scale medical field exercise to be held by the United States Army since 1939. It was conducted this past November at sprawling Ft. Hood, Texas, and was observed by Leonard Riggs, MD, and me representing ACEP and UAEM, respectively. Being somewhat familiar with the organizational structure of the Army, I was curious about how the new specialty of emergency medicine would be utilized in combat. The table of organization and equipment (TO&E) predetermines what personnel and equipment constitute a field hospital or an infantry division. Personnel are categorized by assigning a Military Occupational Specialty (MOS) number. The emergency physician now has reached the status of having an MOS number. Current military doctrine states that when emergency physicians are available in sufficient numbers they will be utilized wherever there is an emergency treatment facility. Because the battalion aid station c u r r e n t l y is staffed by physician assistants, the emergency physician would be assigned primarily to mobile units larger than the aid stations, ie, clearing stations, the 200-bed combat support hospitals, and the 400-bed evacuation hospitals. The success of the military to get the right person in the right job is attributable in large part to assigning personnel based on an MOS number which had been determined by prior training and experience: Thus the emergency physician's military niche is now known. The code name for this exercise was to be '~Texas Laubfrosch." "Laubfrosch" allegedly means treefrog. I did not ask why. Following the early morning briefing we were flown to the forward area where fresh combat ~casualties" were arriving by armored field ambulance. The patients were processed in and around the mobile and armored aid station. The medical person at this level is a physician assistant. The time-proven
80/173
Ann Emerg Med
principles of triage, evacuation, and mobility of patient care facilities are symbolized dramatically at this most forward formal medical facility. In combat the need to keep experienced soldiers in the battle area conflicts with the restriction that the injured soldier places on the combat unit's mobility and willingness to t a k e n e c e s s a r y risk. T h e r e f o r e t r i a g e , emergency care and evacuation will be utilized here just as it will be utilized at each subsequent echelon of care. The casualties were then traced back through the various echelons of care. At each stop through the evacuation chain it was easy to see the physical and procedural format. The military does a superb job of simulating. Because w a r or major disasters" of the magnitude of war are not an everyday occasion, contingency planning and war gaming become an everyday function. The results of this planning made the exercise meaningful. The Army has unique problems in providing emergency medical care in combat. Perhaps the most complex problem is managing patients who not only have high velocity missile or blast wounds but also contamination from nuclear, chemical, or biological warfare. The logistics of dealing with contaminated casualties are both cumbersome and frightening. It is unthinkable in the civilian population, but pervasive in thought and action in the military. The new technology required for surviving in this kind of environment reminds one that there are few options in such an eventuality. There is no levity in seeing scores Of Darth Vader types rendering care in an otherwise standard m i l i t a r y setting. How m a n y physicians would have to concern themselves with how to do CPR in a contaminated environment when both physician and patient are wearing gas masks? It can be done with relatively simple modifications of standard equipment. The opportunity to see and participate in this medical field exercise was both nostalgic and enlight-
10:3 (March) !981
10:3 (March) 1981
Diagnostic Aids: A progressively rising hypera m y l a s e m i a and increased amylase content in the peritoneal lavage fluid are the most useful diagnostic aids for pancreatic injury. The initial serum amylase level correlates poorly with pancreatic injury, primarily because many patients have been drinking prior to injury. A rising s e r u m a m y l a s e from the time of admission until six hours after injury carries a good correlation. Identification of this correlation and utilizing this change as a meanS fSr making an early diagnosis of pancreatic injury m a n d a t e s the routine obtaining of a serum amylase in all patients presenting to the emergency department with blunt abdominal injury, regardless of etiology. Any patient with a question of abdominal tenderness or guarding extending beyond six hours, in conjunction with a rising serum amylase, warrants immediate preparation for surgical intervention and careful exploration of the retroperitoneal area. Preoperative abdominal and thoracic roentgenographs in patients with pancreatic trauma are often normal in the early post-injury period. Later changes include adynamic ileus due to the retroperitoneal inflammation and sometimes a "ground glass" appearance in the midabdominal area due to lesser sac inflammation and fluid accumulation. Intraoperatively, pancreatic injury must be suspected in any patient with a high retroperitoneal or lesser sac hematoma which may extend into the transverse mesocolon,'as is noted in the Saltzstein-Morales case report. Initial resuscitation of the patient presenting with pancreatic injury is the same as for any patient presenting to the emergency department with blunt injury. Initial restoration of volume depletion is provided by means of balanced electrolyte solution, recognizing that the patient may have a significant depletion in both the plasma volume and the interstitial fluid space volume. Depending on the severity of hypervolemia upon arrival in the emergency department, this restoration of volume depletion can be achieved by way of one, two, or three intravenous routes, with one of these routes serving as a central venous catheter monitor in patients with severe plasma volume depletion. Based on studies published elsewhere, the addition of albumin or plasmanate should not be initiated at this time, as this leads to subsequent problems with pulmonary, cardiac, and renal function. P a r t of the initial resuscitation regimen should include nasogastric decompression in order to remove liquid gastric contents and to remove air in order to decrease the likelihood of vomiting when the patient must subsequently undergo exploratory laparotomy
Ann Emerg Med
172/79
with general anesthesia. Following the initial restoration of plasma volume deficit with balanced electrolyte solution, red cell replacement should be provided when the type and crossmatch has been completed: When the patient is not responding to crystalloid or balanced electrolyte solution replacement in the early post-admission period, type-specific blood should be infused to help m a i n t a i n organ profusion until the period when the type and crossmatch has been completed. Severely volume-depleted patients also require full catheter drainage of the bladder in order to monitor ongoing output as a reflection of restoration of plasma volume and renal blood flow. Anticipating the need for subsequent surgical intervention; antibiotics should be initiated; the specific antibiotics utilized vary from institution to institu-
tion, but have generally included penicillin, clindamycin, and gentamycin at this institution. Antibiotics may be discontinued at the time of laparotomy or approximately three to five days after surgery, depending on the severity of pancreatic injury, the status of associated injuries, and~the extent and type of drainage in the postoperative period. Utilizing this regimen of early diagnosis and resuscitation, the vast majority of patients presenting with pancreatic injury can be successfully resuscitated and returned to their normal environment.
Charles E. Lucas, MD, FACS Professor of Surgery Wayne State University School of Medicine Detroit, Michigan
Emergency Medicine and the Military For those of you ~vho have spent time in the military practicing medicine, you will have no trouble understanding what I am about to describe. The occasion was the first full-scale medical field exercise to be held by the United States Army since 1939. It was conducted this past November at sprawling Ft. Hood, Texas, and was observed by Leonard Riggs, MD, and me representing ACEP and UAEM, respectively. Being somewhat familiar with the organizational structure of the Army, I was curious about how the new specialty of emergency medicine would be utilized in combat. The table of organization and equipment (TO&E) predetermines what personnel and equipment constitute a field hospital or an infantry division. Personnel are categorized by assigning a Military Occupational Specialty (MOS) number. The emergency physician now has reached the status of having an MOS number. Current military doctrine states that when emergency physicians are available in sufficient numbers they will be utilized wherever there is an emergency treatment facility. Because the battalion aid station c u r r e n t l y is staffed by physician assistants, the emergency physician would be assigned primarily to mobile units larger than the aid stations, ie, clearing stations, the 200-bed combat support hospitals, and the 400-bed evacuation hospitals. The success of the military to get the right person in the right job is attributable in large part to assigning personnel based on an MOS number which had been determined by prior training and experience: Thus the emergency physician's military niche is now known. The code name for this exercise was to be '~Texas Laubfrosch." "Laubfrosch" allegedly means treefrog. I did not ask why. Following the early morning briefing we were flown to the forward area where fresh combat ~casualties" were arriving by armored field ambulance. The patients were processed in and around the mobile and armored aid station. The medical person at this level is a physician assistant. The time-proven
80/173
Ann Emerg Med
principles of triage, evacuation, and mobility of patient care facilities are symbolized dramatically at this most forward formal medical facility. In combat the need to keep experienced soldiers in the battle area conflicts with the restriction that the injured soldier places on the combat unit's mobility and willingness to t a k e n e c e s s a r y risk. T h e r e f o r e t r i a g e , emergency care and evacuation will be utilized here just as it will be utilized at each subsequent echelon of care. The casualties were then traced back through the various echelons of care. At each stop through the evacuation chain it was easy to see the physical and procedural format. The military does a superb job of simulating. Because w a r or major disasters" of the magnitude of war are not an everyday occasion, contingency planning and war gaming become an everyday function. The results of this planning made the exercise meaningful. The Army has unique problems in providing emergency medical care in combat. Perhaps the most complex problem is managing patients who not only have high velocity missile or blast wounds but also contamination from nuclear, chemical, or biological warfare. The logistics of dealing with contaminated casualties are both cumbersome and frightening. It is unthinkable in the civilian population, but pervasive in thought and action in the military. The new technology required for surviving in this kind of environment reminds one that there are few options in such an eventuality. There is no levity in seeing scores Of Darth Vader types rendering care in an otherwise standard m i l i t a r y setting. How m a n y physicians would have to concern themselves with how to do CPR in a contaminated environment when both physician and patient are wearing gas masks? It can be done with relatively simple modifications of standard equipment. The opportunity to see and participate in this medical field exercise was both nostalgic and enlight-
10:3 (March) !981