Major surgery for abdominal and thoracic trauma in childhood and adolescence

Journal of Pediatric Surgery VOL. IX, NO. 2

APRIL 1974

M a j o r Surgery for A b d o m i n a l and Thoracic T r a u m a in Childhood and A d o l e s c e n c e By Michael C. Sinclair and Thomas C. Moore

ERIOUS TRAUMA has reached epidemic proportions in our complex, urban, mechanized societies. Injuries are the leading cause of death in children, adolescents, and young adults. Forty per cent of the children who die in the United States, die because of accidents. ~ In addition to the 13,000 children who are killed annually an estimated 100,000 are permanently disabled/ Motor vehicles account for 40% of the fatalities. Penetrating injuries are also increasing and while shooting and stabbing are largely "adult" phenomena, a significant proportion of the incidents involve adolescents. In this study charts of all patients under 19 who underwent laparotomy and/or thoracotomy in the treatment of trauma at the UCLA-Harbor General Hospital from October 1961 through April 1972 were reviewed. Cases of iatrogenic trauma were excluded.

S

DISTRIBUTION OF INJURIES

There were 199 patients: 99 blunt injuries and 100 penetrating injuries (60 stab wounds and 40 gunshot wounds). One hundred and eighty-six laparotomies, four thoracotomies, and nine combined thoracic and abdominal operations were performed. Ninety-five per cent of the operations were done by the house staff. Males outnumbered females 5:1 in penetrating injuries and 2:1 in blunt trauma (Fig. 1). Most penetrating injuries occurred in adolescents, but young children occasionally were involved. The youngest patient was an 1 l-too-old boy shot accidently by his father. Nonpenetrating injuries occurred in all age groups with a distinct bimodal distribution. The first peak occurred in the 5- to 7-yr age range, the second in late adolescence. This distribution is explained by Fig. 2 which shows the mode of injury in the two age groups. From the Pediatric Surgical Service, UCLA Harbor General Hospital, Torrance, Calif. and the Department of Surgery, University of California, Los Angeles, Calif. Michael C. Sinclair, M.D.: Chief, Resident in Surgery, Harbor General Hospital, Torrance, Calif. Thomas C. Moore, M.D.: Chief, Pediatric Surgery and Renal Transplantation, Harbor General Hospital, Torrance, Calif.; Professor of Surgery, University of California, Los Angeles, Calif. Address for reprint requests: Thomas C. Moore, M.D., Chief Pediatric Surgery and Renal Transplantation, Torrance General Hospital, 1000 W. Carson St., Torrance, Calif. 90509. 9 1974 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 9, No. 2 (April). 1974

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156

12

0

~1

Fig. 1.

2

3

4

5

6

7

8 9 I0 II AGE IN YEARS

12

1'5

14

15

16

17

18

Age and sex distribution of blunt and penetrating trauma.

Blunt Trauma

Table 1 lists th e organs injured by blunt trauma. As expected, splenic rupture was the most c o m m o n (43 patients). The liver was the second most frequently injured organ. In 7 of 22 patients (31.8~) the injury was considered severe; two died of exsanguination; both had associated inferior vena cava lacerations. One 16-yr-old boy underwent resection o f the fractured right lobe of the liver. He experienced a stormy course postoperatively which included massive upper gastrointestinal bleeding and sepsis. He died on the 51st postoperative day. The other patient who underwent right hepatic lobectomy, a 17-yr-old boy, had a postoperative course which was marked by fever, jaundice, and a pleural effusion. He ultimately recovered. Three additional patients had T-tube choledochostomies for biliary decompression, and the remainder were treated with simple suture a n d / o r drainage. Nine patients had renal contusions, and l I had renal lacerations. In one instance, the kidney laceration was repaired, in one a partial nephrectomy performed; the remaining nine lacerated kidneys were removed. All seven pancreatic injuries were contusions which were treated using multiple drains. One patient with a severe contusion of the head of the pancreas and retroperitoneal rupture of the d u o d e n u m had repair of the duodenal rupCHILDREN (Z.AGE 12)

\

11 \ ~

/

/

I X I. . . . ~

ACCIDENT (OCCUPANT) (8.6%) Fig. 2.

ADOLESCENTS (>AGE 12)

OTORCYCLE AND / OTHER AND / UNKNOWN 110.3~

~

/ I P

~ E

~

.OTOR VEHICLE ~

DEo, nlAN(12,2%)

OTHER'AND UNKNOWN (4.9%) Source of blunt trauma: children and adolescents.

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ABDOMINAL AND THORACIC TRAUMA

Table 1. Organs injured in Blunt Trauma--99 Patients Number Solid viscera

Spleen Liver Kidney

43 22

Pancreas

20 7

Hollow viscera Duodenum

4

Small intestine Bladder

3 5

Ureter Gallbladder

2 1

Intraabdominal vessels Inferior veno cava

Hepatic artery Bronchopulmonary structures Miscellaneous

None

4 1 3 6 16

ture, drainage of the pancreas, and a T-tube choledochostomy. Another complex duodenal injury occurred in a 16-yr-old motorcyclist who had a complete disruption of the pylorus, a tear in the superior mesenteric vein, a rupture of the rectus abdominus, and a fracture-dislocation of the lumbosacral spine. His postoperative course was complicated by upper gastrointestinal bleeding and gastric outlet obstruction which necessitated reoperation. This patient recovered. The three patients with small intestinal injuries had isolated ruptures of the proximal jejunum; all were treated by simple repair or resection and all recovered. Five patients with urinary bladder ruptures had pelvic fractures. Two had avulsion of the bladder neck from the prostatic urethra. There were two complete transections of a ureter, one associated with a ruptured spleen and one as an isolated injury. Four patients had lacerations of the inferior vena cava, all of them fatal. In one the laceration was at the junction of the inferior vena cava and the right atrium and in another there was concomitant avulsion of the hepatic artery. Three patients had major bronchopulmonary injuries. One 8-yr-old boy died of multiple injuries including bilateral rib fractures, a laceration and contusion of the left lung, a pelvic fracture with an avulsed bladder, and a ruptured spleen. A 3-yr-old boy died of similar multiple injuries including transection of the bronchus and vessels of the left upper lobe. One 14-yr-old girl who presented with a right-sided flail chest and tension p n e u m o t h o r a x had a successful repair of a completely transected right mainstem bronchus. Sixteen per cent of the patients sustaining blunt trauma were found at operation to have no injury requiring repair.

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Table 2. Organs Injured in Penetrating Trauma--100 Cases Number Solid viscera Spleen Liver Kidney Pancreas

2 30 5 3

Hollow viscera Stomach Duodenum Small intestine Colon Bladder Gallbladder

10 3 25 17 I 3

Major vessels Aorta Iliac artery and vein Subclavian artery and vein Inferior vena cava

2 3 1 1

Other Diaphragm Heart Bronchopulmonary structures Miscellaneous

7 3 2 7

None

26

Table 3. Associated Injuries in 99 Patients with Blunt Thoracic and Abdominal Trauma Type of Injury

Number of Cases

Head injuries Skull fractures Brain contusion Brain concussion Epidural hematoma

28 12 12 11 1

Thoracic injuries Hemothorax and/or pneumothorax Pulmonary contusion

11 8 3

Fractures (excluding skull) Pelvis Femur Other lower extremity Spine Ribs Shoulder girdle Other upper extremity Manibulofacial

47 19 15 6 3 11 12 9 4

None

39

ABDOMINAL AND THORACIC TRAUMA

159

Penetrating Trauma The organs injured in penetrating trauma are shown in Table 2. The liver was the most frequently injured organ (30 cases). However, in only four cases (13~o) was the injury considered severe enough to require biliary decompression. All of these injuries were from gunshot wounds. All penetrating renal and pancreatic injuries were managed without nephrectomy or pancreatectomy. Small bowel and colon enterotomies were three times as common in gunshot victims as in those who had been stabbed. Stomach injuries, on the other hand, occurred with equal frequency in the two groups. Cholecystectomies were performed in the three patients with penetrating gallbladder injuries and all survived. Seven patients had major vascular injuries. One boy with a gunshot wound of the aorta died of exsanguination. Another died after repair of a transected iliac artery. This patient will be discussed later. Two patients with stab wounds of the right ventricle recovered without complications after operations for pericardial tamponade. In contrast, a patient With a gunshot wound of the left ventricle upon whom immediate thoracotomy was carried out died. Twenty-six per cent of the patients with penetrating trauma were found at operation to have no injury which required repair.

Associated Injuries Significant extraabdominal injuries occurred in 12~ of the cases of penetrating trauma. Eight of the 12 were hemothoraces and/or pneumothoraces, usually from a thoracoabdominal wound which led to laparotomy. In one gunshot wound the missile struck the spinal cord and resulted in paraplegia. In contrast, 61~ of patients who experienced blunt injuries had major associated injuries (Table 3). Twenty-eight had significant head injuries; six were fatal. The occurrence of skull fracture did not correlate well with the gravity of central nervous system injury. Eight patients had hemothorax and/or pneumothorax, and three had pulmonary contusions. Forty-seven patients had one or more fractures (excluding skull fractures). Fifteen had fractures of a femur and 19 had pelvic fractures. Approximately one-quarter of this latter group had ruptured bladders. One spinal fracture was associated with paraplegia.

Deaths There were i2 deaths from blunt trauma (Table 4). The six patients who died on the operating table, four with inferior vena cava lacerations and two with bronchopulmonary lesions, have been discussed earlier as was the patient who died of sepsis after right hepatic lobectomy. Three patients died from central nervous system injuries within hours of operation. One patient died 3 days after injury from an unrecognized epidural hematoma. One 3-yr-old boy who was found at operation to have a pancreatic contusion and a hematoma of the gastrocolic and hepatoduodenal ligaments died suddenly on the sixth postoperative day. Autopsy revealed a thrombosis of the inferior vena cava from the level of the pancreas to the right atrium.

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Table 4. Deaths and Complication Rates in Blunt and Penetrating Trauma Trauma PenetrQting Blunt Cases Deaths Mortality rate Patients surviving more than 1 day Cases With complications Complication rate

99 12 12% 90 30 33%

Gunshot 40 4 10% 38 14 36%

Stab 60 0 0% 60 7 12%

Four patients in the penetrating injury group died. The deaths from gunshot wounds of the heart and aorta were previously mentioned. Another patient with hypovolemic shock from a gunshot wound of the iliac artery died on the fourth postoperative day from posttraumatic respiratory insufficiency. His course was complicated by the transfusion of six units of mismatched blood. The fourth death occurred in a 15-yr-old girl with a gunshot wound of the colon who developed a flank abscess and septic shock.

Complications The complication rate of 36~o for gunshot wounds was similar to that of 33~o for blunt injuries, whereas the complication rate for stab wounds (12~o) was significantly lower. Pneumonia and pyogenic infections were frequent in both groups (Table 5). Most pleura[ effusions were secondary to intraabdominal abscesses, and the majority of intraperitoneal abscesses were related to liver injuries in the blunt trauma group and colon injuries in the penetrating trauma group. Blunt and penetrating trauma are compared with respect to complications, mortality, associated injuries, and "unnecessary" operations, as determined in retrospect, in Table 6. Table 5. Types of Complications--Blunt and Penetrating Trauma Trauma Complication

Blunt

Pulmonary complications Pneumonia Pleural effusion Pneumotharox Shock lung

13

Infections Deep abscess Wound infection Sepsis

10

Penetrating 6

6 5 2 2

4 3 2 10

10 1 3

4 5 1

Poncreatitis

5

2

Upper gastrointestinal bleeding

3

0

15

6

Other

ABDOMINAL AND THORACIC TRAUMA

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Table 6. Comparison of Blunt and Penetrating Trauma Truarna Blunt

Mortality Associated injuries Complications "Negative laparotomies"

12% 61% 29% 10%

Penetrating 4% 12% 21% 26%

DISCUSSION

Auto versus pedestrian accidents accounted for 67% of the blunt childhood injuries in this series and for 41% and 62.3% of the blunt injuries in the pediatric age group in reports from two other large municipal hospitals. 3'4 The type of trauma seen at a pediatric referral center was quite different. 5 Penetrating injuries in childhood are u n c o m m o n in all reports. Adolescents sustained twice as many penetrating injuries as blunt injuries. In addition, the source of the blunt trauma was more varied in the teen-age group. In most series, the largest number of pediatric blunt trauma victims were 5-8 yr old. 3-5 What has not been stressed, however, is the disproportionately high risk of death among the very young. The death rates for blunt trauma victims under 5 years of age were 42% in this series and 40% in Levey's report as compared with overall mortality rates of 12~ and 14.6% respectively. 4 The spectrum of organs injured was similar to that encountered in most reported series. 3'6 We found no reason to alter our policy of exploratory laparotomy when a ruptured spleen was suspected despite a recent report by Douglas and Simpson] They suggested that some of these children might be managed nonoperatively. Paracentesis and peritoneal lavage were useful adjuncts for the diagnosis of hemoperitoneum, peritoneal lavage being the more reliable of the two. The high frequency with which blunt trauma victims have associated extraabdominal injuries attests to the severity and complexity of their trauma. Fractures were the most c o m m o n other injuries in this series as well as in others. Central nervous system injuries were particularly lethal, accounting for onethird of the deaths in this experience and even higher proportions in some other series. The majority of the remaining deaths were from exsanguination. Perry's observation that only 38% of the children who died from accidents reached the hospital alive emphasizes the inherent limitation of increased sophistication of in-hospital trauma management in reducing mortality from accidents .8 The benignity of stab wounds as compared with gunshot wounds with respect to organs injured, postoperative complications, and deaths was striking. Although we were aggressive in this experience relative to performing exploratory laparotomies for abdominal stab wounds, the 26% incidence of "negative" laparotomies for penetrating trauma (35% for stab wounds) was disturbing. Operations also were probably unnecessary in a number of cases in which a small, nonbleeding liver laceration was the only finding at exploration. Reported experiences of others with the selective, nonoperative management of

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stab wounds have led us to adopt a less aggressive operative approach in this area. 9-1[ SUMMARY

One hundred and ninety-nine cases of major abdominal and thoracic surgical procedures for trauma in childhood and adolescence have been reported. Onethird were in children under 13. The ratio of blunt to penetrating trauma was 8:1 in the childhood group with most injuries occurring in the 5- to 7-yr age range. The highest death rate occurred in children under 5. In adolescents, the ratio of penetrating to nonpenetrating trauma was 2:1. The mortality rates for blunt and penetrating trauma were 12~ and 4 ~ , respectively. Associated injuries were five times more frequent in the blunt trauma group. Complications developed in one-third o f the cases of blunt trauma and one-fifth of the cases of penetrating injuries. All deaths and most of the complications in the latter group were from gunshot wounds. The frequency of unnecessary exploratory operations was greater in the penetrating injury group. REFERENCES 1. Vital Statistics of the United States. Volume II, Mortality, Part A, 1960-67. U.S. Dept. Health Education and Welfare. 2. Morse TS: Trauma: A call to action. Talk presented at The American Pediatric Surgical Association Trauma Workshop. Hotsprings, Va., April 12, 1972 3. Welch K J: Abdominal and thoracic injuries, in W.T. Mustard (ed): Pediatric Surgery (ed 2), vol. 1, Chicago, Yearbook, 1969, p 708 4. Levey JL Jr, Linder LH: Major abdominal trauma in children. Am J Surg 12:55, 1970 5. Tank ES, Eraklis A J, Gross RE: Blunt abdominal trauma in infancy and childhood. J Trauma, 8:439, 1968 6. Richardson, JD, Belin RP, Griffen WO Jr: Blunt abdominal trauma in children. Ann Surg 176:213, 1972 7. Douglas G J, Simpson JS: The conserva-

tive management of splenic trauma. J Pediatr Surg 6:565, 1971 8. Perry J: Discussion of blunt abdominal trauma in infancy and childhood by Tank ES, et al: J Trauma 8:448, 1968 9. Richter RM, Zakai MH: Selective conservative management of penetrating abdominal injuries. Surg Gynecol Obstet 130:667, 1970 10. Haddad GH, Pizzi WF, Fleischmann EP, et al: Abdominal signs and sinograms as dependable criteria for the selective management of stab wounds of the abdomen. Ann Surg 172:61, 1970 11. Wilder JR, Lotfi MW, Jurani P: Comparative study of mandatory and selective surgical intervention in stab wounds of the abdomen. Surgery 69:546, 1971