Acta Chirurgica Belgica

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Predicting Factors for Mortality in the Penetrating

Abdominal Trauma

M. Aldemir, I. Taçyildiz & S. Girgin

To cite this article: M. Aldemir, I. Taçyildiz & S. Girgin (2004) Predicting Factors for Mortality in the
Penetrating Abdominal Trauma, Acta Chirurgica Belgica, 104:4, 429-434

To link to this article: http://dx.doi.org/10.1080/00015458.2004.11679587

Published online: 07 Nov 2016.

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Acta chir belg, 2004, 104, 429-434

Predicting Factors for Mortality in the Penetrating Abdominal Trauma

.
M. Aldemir, I . Taçyıldız, S. Girgin
Department of General Surgery, Dicle University, Faculty of Medicine, Turkey.

Key words. Penetrating abdominal trauma ; mortality : predicting factors.

Abstract. Purpose : penetrating abdominal trauma (PAT) is still a serious problem all over the world. This study was
made to define and discuss the factors that could affect mortality in the PAT.
Methods : the records of 1048 patients hospitalized and operated for PAT at Dicle University Hospital (DUH) between
January 1990 and December 2001 were retrospectively reviewed. Patients (n = 1048) were divided into two groups :
“Healthy Group” (HG) (n = 942) and “Deathly Group” (DG) (n = 106). The epidemiological and clinical features were
evaluated as probable risk factors for mortality. The risk factors for mortality were revealed using univariate and multi-
variate analyses.
Results : a total of 1048 patients [937 (89.4%) male, 111(10.6%) female] with PAT were included in this study. The mor-
tality rate (22.5%) of female patients was significantly higher than (8.6%) that of male patients (p = 0.000). The mean
age was 30.01 ± 63.9 (14-74) years and 30 ± 12.5(15-71) years in the HG and DG consecutively (p = 0.85). The aver-
age interval between injury and operation (IBIO) was 2.09 ± 1.3 (0.5-3) and 6.9 ± 11.4 (1-6.1) hours in the HG and DG
respectively (p = 0.000). Presence of shock on admission (PSDA) was determined in 87 patients and in 96 patients in
the HG and DG respectively (p = 0.000). The mortality rate (14.9%) in patients presenting gunshot wounds (GSW) was
significantly higher than (2.7%) that of patients with stab wounds (SW) (p = 0.000). The average number of injured
intraabdominal organs (NIAOI) was 1.98 ± 1.08 (1-7) and 4.67 ± 1.99 (1-13) in the HG and DG respectively (p = 0.000).
Mortality rates were 72.7% in cardiac injury, 30% in great vessels injuries, 32.6% in cranial injury, and 21.5% in major
extremity and pelvic injury (p = 0.000). The average penetrating abdominal trauma index (PATI) was 11.78 ± 9.44 (1-
58) and 46.24 ± 22.18 (15-119) in the HG and DG respectively (p = 0.000).
In multivariate analyses, female gender [Odds Ratio (OR) = 10.74, 95% Confidence Interval (CI) = 3.03-38.12,
P = 0.000], the long IBIO (OR = 1.82, CI = 1.39-2.40, P = 0.000), PSDA (OR = 94.45, CI = 28.32-314.95, P = 0.000),
presence of cranial injury (OR = 0.03, CI = 0.002-0.363, P = 0.006) and high PATI (OR = 1.14, CI = 1.09-1.19,
P = 0.000), were found significantly important for mortality.
Conclusion : we determined that conditions such as, female gender, long interval between injury and operation,
presence of shock on admission, presence of cranial injury and high PATI were predicting factors for mortality in PAT.

Introduction and morbidity in these civilian settings have been studied

Trauma is still the most frequent cause of death in the
first four decades of life. Today, trauma remains a main
public health problem in every country, regardless of the
level of socio-economic development. For example,
trauma is responsible for 25% of the deaths in the USA.
It is also the leading cause of death in people from 1 to
44 years of age. In order to minimize the mortality rate
associated with trauma, the factors affecting mortality
should be evidenced to take care of patients. In the late
years, the studies have been aimed at determining the
preventable trauma cases (1, 2).
The development of efficient ambulance services,
blood banks and regional trauma centres have con-
tributed to the reduction of mortality to 9.5% in the
1990s (3-8). Early death secondary to exsanguinations
haemorrhage has been replaced by delayed death due to
infection (9,10). The risk factors influencing mortality
(10-13). Elsewhere, prolonged prehospital time, inade-
quate supply of blood for transfusions and the high rate
of colon injury contribute to a relatively high incidence
of postoperative infectious complications and death (14).
It was determined that PATI score, number of postopera-
tive complications per patient and presence of shock on
admission were independently significant factor in pre-
dicting mortality in patients with abdominal GSW (13).
This is why, this study was performed retrospectively
to define and discuss the factors that could affect the
mortality in the PAT.
Patients and methods
The DUH, a tertiary referral centre and the largest hos-
pital in Southeast Turkey, cares for the vast majority of
patients with traumatic injury who are transferred from
other hospitals. Using a standardized data collection
430
instrument, case records of all patients with penetrating
trauma diagnosed between January 1990 and December
2001 at DUH were reviewed. All patients who had emer-
gency laparotomy after sustaining GSW and SW were
included in the study.
Patient characteristics (age and gender), aetiology of
trauma (GSW/SW), IBIO, PSDA, NIAOI, thoracic
injury (haemo-pneumothorax and/or pulmonary injury),
penetrating cardiac injury, great vessels injury (intra-
abdominal/thoracic), cranial injury, major extremity and
pelvic injury and PATI were recorded. The relationship
netween these factors and mortality was investigated.
IBIO was defined as the period between injury and
operation and it was calculated according to the infor-
mation collected from the patient himself or his/her
escorts. Shock on admission was defined as systolic
pressure of less than 80 mm Hg and pulse rate greater
than 100 per min. In GSW, time-consuming radiological
or laboratory analyses were not carried out in case of
positive peritoneal irritation and/or of presence of peri-
toneal penetration. In case of SW, the haemodynamical-
ly stable patients and those with no peritoneal findings
in the first physical examination, or those suspected of
such findings, were candidates for laparotomy after per-
forming some diagnostic attempts such as local wound
exploration and abdominal ultrasonography. When there
was no countraindication, nasogastric tube, urethral
catheter and central venous catheter were performed
routinely. While an antibiotic of the cephalosporin group
was given for prophylaxis, an antibiotic with anaerobic
spectrum (metronidazole or clindamycin) was also
included in the treatment. In all patients midline laparo-
tomy was performed. In the thoracic injuries, thoracoto-
my and/or chest-tube drainage were performed. Bullets,
bullet fragments and pellets in the operation field were
extracted. After the completion of all repairs, peritoneal
and wound lavage with copious isotonic saline, the peri-
toneum, fascia, subcutaneous tissue and skin were
closed. NEAI and NIAOI were all recorded. The PATI
score for each patient was calculated as described by
MOORE et al. (15) (Table 1). The Glasgow Coma Scale
(GCS) was calculated in the patients who had cranial
injury. The death in the first 48 hours was considered as
early mortality.
All epidemiological, clinical and operative features
were recorded for probable risk factors for mortality.
Findings for risk factors included : age, gender, aetiolo-
gy of trauma, IBIO, PSDA, thoracic injury, penetrating
cardiac injury, great vessels injury, cranial injury, major
extremity and pelvic injury, NIAOI and PATI.
Statistics
All data were entered into a statistical model for
analysing mortality factors for PAT and were performed
M. Aldemira et al.
using SPSS (SPSS 10.0 for Windows, SPSS Inc.). For all
univariate analyses, a chi-square test was used for bina-
ry variables and a student’s t-test for continuous vari-
ables. To assess predictors of mortality, multivariable
analysis using logistic regression was performed.
Candidate variables either of biological importance or
those with a p value < 0.2 were entered using a back-
wards, step-wise approach. Predictor variables were
kept in the final model if p < 0.05.
Results
A total of 1048 patients [937 (89.4%) male, 111 (10.6%)
female] with PAT were enrolled in this study. Of
1048 patients, 942 (89.9%) were in the HG, and 106
(10.1%) were in the DG. The mortality rate of female
patients (22.5%) was significantly higher than that of
male patients (8.6%) (p = 0.000). The mean age was
30.01 ± 63.9 (14-74) years and 30 ± 12.5 (15-71) years
in the HG and DG respectively and there was no statis-
tical difference related to age between the HG and DG
(p = 0.85) (Table 2).
The average IBIO was 2.09 ± 1.3 hours (range from
0.5 hours to 3 hours) and 6.9 ± 11.4 hours (range from
1 hours to 6.1 hours) in the HG and DG respectively
(p = 0.000). During admission, the shock was diagnosed
in 87 patients and in 96 patients in the HG and DG
respectively and PSDA was a significant factor for mor-
tality (p = 0.000) (Table 2).
Of all patients, 639 patients (61%) due to GSW d 409
(39%) patients due to SW were operated on. The mor-
tality rate of patients subjected to GSW (14.9%) was
significantly higher than that of patients exposed to SW
(2.7%) (p = 0.000). The average NIAOI was 1.98 ± 1.08
(range from 1 to 7) and 4.67 ± 1.99 (range from 1 to 13)
in the HG and DG respectively (p = 0.000). Thoracic
injury was determined in 225 patients and in 28 patients
in the HG and DG respectively (p = 0.564). Mortality
rates were 72.7% in cardiac injury, 30% in great vessels
injuries, 32.6% in cranial injury, and 21.5% in major
extremity and pelvic injury (p = 0.000). The mean GCS
of patients who had cranial injury were 12.63 ± 1.88
(range from 9 to 15) and 10.28 ± 3.17 (range from 3 to
14) in HG and in DG respectively (p = 0.015). The aver-
age PATI was 11.78 ± 9.44 (range from 1 to 58) and
46.24 ± 22.18 (range from 15 to 119) in the HG and DG
respectively (p = 0.000) (Table 2).
The overall mortality rate for PAT in our series was
10.1% (n = 106). Of 106 patients, 67 (63.2%) died in the
first 48 hours due to shock, disseminated intravascular
coagulation, acute respiratory distress syndrome and/or
pulmonary emboli, 39 (36.8%) died in the postoperative
60-day due to sepsis, gastrointestinal fistula and/or mul-
tiple organ dysfunction.
Predicting Factors for Mortality in the Penetrating Abdominal Trauma 431

Table 1 3. Minor debridement

Calculation of the PATI* from MOORE et al. (15) 4. Segmental resection
5. Reconstruction
* Based on assigning a complication risk factor (x) to each Bladder (2) 1. Single wall
organ system involved and grading each organ injury (1 = 2. Through-and-through
minimal, 2 = minor, 3 = moderato, 4 = major, 5 = maximum). 3. Debridement
4. Wedge resection
Organ injured Risk Scoring 5. Reconstruction
factor Bone (1) 1. Periosteum
Duodenum (5) 1. Single wall 2. Cortex
2.
25% wall 3. Through-and through
3. > 25% wall 4. Intra-articular
4. Duodenal wall and blood supply 5. Major bone loss
5. Pancreaticoduodenectomy Minor Vascular (1) 1. Non bleeding small haematoma
Pancreas (5) 1. Tangential 2. Non bleeding large haematoma
2. Through-and-through (Duct Intact) 3. Suturing
3. Major debridement or distal duct 4. Ligation of isolated vessels
injury 5. Ligation of named vessels
4. Proximal duct injury
5. Pancreaticoduodenectomy
Liver (4) 1. Non bleeding peripheral
2. Bleeding, central, or minor debride-
ment The predicting factors for mortality in the PAT were
3. Major debridement or hepatic artery
revealed using univariable and multivariable analyses.
ligation
4. Lobectomy Age, gender, aetiology of trauma, IBIO, PSDA, thoracic
5. Lobectomy with caval repair or injury, penetrating cardiac injury, great vessels injury,
extensive bilobar debridement cranial injury, extremity and pelvic injury, NIAOI and
Large intestine (4) 1. Serosal PATI were entered into the univariable model. In uni-
2. Single wall
variate analyses, female gender, the long IBIO, GSW,
3.
25% wall
4. > 25% wall penetrating cardiac injury, great vessels injury, cranial
5. Colon wall and blood supply injury, major extremity and pelvic injury, PSDA, high
Major Vascular (4) 1.
25% wall PATI and NIAOI were found significantly associated
2. > 25% wall with mortality (Table 2).
3. Complete transection
These variables were entered into the logistic regres-
4. Interposition grafting or bypass
5. Ligation sion model for revealing the risk factors for mortality. In
Spleen (3) 1. Non bleeding multivariate analyses, female gender (OR = 10.74, CI =
2. Cautery or haemostatic agent 3.03-38.12, P = 0.000], the long IBIO (OR = 1.82, CI =
3. Minor debridement or suturing 1.39-2.40, P = 0.000), PSDA (OR = 94.45, CI = 28.32-
4. Partial Resection
314.95, P = 0.000), presence of cranial injury (OR =
5. Splenectomy
Kidney (3) 1. Non bleeding 0.03, CI = 0.002-0.363, P = 0.006) and high PATI (OR =
2. Minor debridement or suturing 1.14, CI = 1.09-1.19, P = 0.000), were found signifi-
3. Major debridement cantly important for mortality (Table 3).
4. Pedicle or major calyceal
5. Nephrectomy
Discussion
Extrahepatic (3) 1. Contusion
biliary 2. Cholecystectomy
3.
25% common duct wall Trauma-related deaths tend to occur at three traditional-
4. > 25% common duct wall ly recognized times after injury. About half of all trau-
5. Biliary enteric reconstruction ma-related deaths occur within seconds or minutes of
Small intestine (2) 1. Single wall
injury. The second mortality peak occurs within the
2. Through-and-through
3.
25% wall or 2-3 injuries hours following injury and accounts for about 30% of
4. > 25% wall or 4-5 injuries deaths, half of which are caused by haemorrhage and
5. Wall and blood supply or > 5 injuries half by injuries to the central nervous system. Because
Stomach (2) 1. Single wall many of these deaths can be averted by early treatment
2. Through-and-through
during the “golden hour” after injury, important reduc-
3. Minor debridement
4. Wedge resection tions in second peak mortality have resulted from the
5. > 35% resection development of rapid transport and trauma treatments.
Ureter (2) 1. Contusion The third mortality peak includes deaths that occur from
2. Laceration 1 day after injury to weeks later. This late mortality is
432 M. Aldemira et al.

Table 2
Univariate analysis of potential predictors for mortality in patients exposed to PAT.
* Data : mean value ± standard deviation (min-max).
HG = Healthy group, DG = Deathly group, PAT = Penetrating abdominal trauma, GSW = Gunshot wounds, SW = Stab wounds, PSDA = Presence
of shock during admission, PATI = Penetrating abdominal trauma index, IBIO = Interval between injury and operation, NIAOI = number of intra-
abdominal organs injured.

Parameters HG (n) DG (n) Mortality rate n (%) P value

Gender
Female 86 25 25/111 (22.5) = 0.000
Male 856 81 81/937 (8.6)
Aetiology of PAT
GSW 544 95 95/639 (14.9) = 0.000
SW 398 11 11/409 (2.7)
PSDA 87 96 96/183 (52.5) = 0.000
Organs injured
Thoracic injury 225 28 28/253 (11.07) = 0.564
Cardiac injury 3 8 8/11 (72.7) = 0.000
Great vessels 49 21 21/70 (30) = 0.000
Cranial injury 29 14 14/43 (32.6) = 0.000
Extremity and pelvic injury 73 20 20/93 (21.5) = 0.000
Age * 30.01 ± 63.9 (14-74) 30 ± 12.5 (15-71) = 0.85
IBIO (hours) * 2.09 ± 1.3 (0.5-3) 6.9 ± 11.4 (1-6.1) = 0.000
NIAOI * 1.98 ± 1.08 (1-7) 4.67 ± 1.99 (1-13) = 0.000
PATI * 11.78 ± 9.44 (1-58) 46.24 ± 22.18 (15-119) = 0.000

Table 3
Multivariate analysis of potential predictors for mortality in the PAT.
*Backward stepwise (Wald) logistic regression.
HG = Healthy group, DG = Deathly group, PAT = Penetrating abdominal trauma, PSDA =
Presence of shock during admission, PATI = Penetrating abdominal trauma index, IBIO =
Interval between injury and operation.

Factors P value Odds 95% confidence interval

ratio* (Lower-Upper)*
Female gender = 0.000 10.74 3.03-38.12
The long IBIO = 0.000 1.82 1.39-2.40
PSDA = 0.000 94.45 28.32-314.95
Presence of cranial injury = 0.006 0.03 0.002-0.363
High PATI = 0.000 1.14 1.09-1.19

usually attributed to infection and multiple organ failu-
re (2). In our series, the overall mortality rate for PAT
was 10.1. Of this patients, 63.2% died in the first
48 hours due to shock, disseminated intravascular
coagulation, acute respiratory distress syndrome and/or
pulmonary emboli and 36.8% died in the postoperative
60-day due to sepsis, gastrointestinal fistula and/or
multiple organ dysfunction.
Age is an important factor for mortality in trauma
cases. Mortality significantly increases in patients over
50, even if there is no associated illness (1). However, in
this study, there was no statistical difference related to
age between the HG and DG. The mortality rate of
female patients (22.5%) was significantly higher than
that of male patients (8.6%) in the univariate and multi-
variate analysis. This may be related to the fact that the
number of male patients was higher than that of female
patients. At the same time, in our study, rate of female
patients who were exposed to GSW (76.6%) was higher
than that of male patients exposed to GSW (59.3%).
One of the most important factors affecting mortality
was the trauma factor. It has been reported that mortali-
ty is very low in cases with SW while it is very high in
cases with GSW (16). In our series, mortality was also
high in GSW cases compared with SW cases in univari-
ate analysis. The fact that most of our patients were
wounded with highly effective fire guns increased the
difference in the mortality rate in GSW and SW. We
believe that mortality increased not only because of the
higher number of abdominal organ injuries but also
because of massive tissue damage. Penetrating trauma
involves the transfer of energy to a relatively small tissue
Predicting Factors for Mortality in the Penetrating Abdominal Trauma
area. The velocity of a gunshot wound is exceedingly
high compared with any type of blunt trauma. The
kinetic energy of a bullet disrupts and fragments cells
and tissues, moving them away from the path of the
bullet. Low energy missiles include knives and other
objects that produce damage only by their sharp cutting
edges. Cavitation is minimal, and injury can be predict-
ed simply by tracing the pathway of the weapon within
the body (2).
BAKER et al. (17), have reported that the interval
between injury and treatment is an important factor
affecting mortality. The longer the interval, the higher is
the risk of shock in patients. Besides, a long interval
increases also the severity and duration of shock (17). In
this study, the average IBIO in the HG was significantly
lower than that of DG in univariate and multivariate
analysis. The development of a trauma system within a
geographic area provides for access to trauma care and
rapid transport of major trauma victims to specific hos-
pitals within that region. The development of trauma
systems has resulted in a significant reduction in patient
mortality within the first hours after injury (2).
Important risk factors found to be associated with the
development of postoperative infectious complications
in patients with GSW of the abdomen, include shock on
admission, duration of operation, transfusion require-
ments, number of organs injured and PATI score (10,
12). In most studies, conducted on the cases with trau-
ma, the hypovolaemic shock has been reported to be the
most important cause of death (1, 16, 18-20). The sever-
ity and duration of shock directly affect morbidity and
mortality. BRITT et al. (21) reported that shock played a
varying role, from 5.5 to 100 in the death cases. Also in
our studies, at admittance a hypovolaemic shock was
determined in 52.5% of cases. We determined in the
logistic regression analysis that PSDA was a significant
predicting factor for mortality.
Previous studies have shown that in military and
civilian abdominal gunshot wounds, mortality rate rises
with the number of intraabdominal organs injured (11,
13, 22, 23). The number of injured organs and the degree
of injury depend upon the severity of trauma. When the
severity of trauma increases, the number of injured
organs, morbidity and mortality also increase (15). Like
others, we determined that there was a positive correla-
tion between the number of organs injured and mortali-
ty in univariate analysis. However, the number of organs
injured does not accurately quantify the overall severity
of injury. The PATI score is a more accurate method of
quantifying the extent of damage to different organs and
therefore is a more valid index of overall severity of
injury. PATI is the most frequently used scoring system
to estimate the risk of morbidity and mortality by deter-
mination of the severity of trauma in the penetrating
injuries. Though this index, defined by MOORE et al., is
433
more important in determining the risk of morbidity, it is
also used for mortality (15). The number of injured
organs in cases with GSW is generally more elevated
than that in cases with SW. Therefore ; PATI scores
higher in patients exposed to GSW (16). Our study
showed that PATI score correlated with mortality in both
univariate and multivariate analysis.
Head trauma have the highest risk of mortality in
extraabdominal injuries. In all trauma, cranial injuries
have been reported to be responsible for almost 50% of
the death causes. This is followed by the heart and aorta
injuries (24). DOVE et al. (25) have reported that isolated
cranial trauma were responsible for 30% of the whole
mortality caused by trauma. In our series, mortality rate
was 32.6% in patients with cranial injury. We deter-
mined that presence of cranial injury correlated with
mortality in both univariate and multivariate analysis.
Thoraco-abdominal injuries are combined wounds
involving the organs of the two neighbouring body cav-
ities, with concomitant damage to their anatomical par-
tition, the diaphragm. The prevalence of these injuries is
about 10% of all wounds to the thorax and abdomen.
Wounds to right side have been more frequently
described, allegedly because wounds to the left side are
more fatal (26, 27). In our study, prevalence of penetrat-
ing thoraco-abdominal injuries was 24.1% and mortali-
ty rate of this injury was 11.07%. However, thoracic
injury was not a predictive factor for mortality. This may
be related to a large number of SW and wounds to the
right side. Other mortality rates were 72.7% in cardiac
injury, 30% in great vessels injuries, and 21.5% in major
extremity and pelvic injury. We showed that each three-
organ injury was significantly related to mortality in uni-
variate analysis.
In conclusion, we determined that conditions such as,
female gender, the long interval between injury and
operation, presence of shock during admission, presence
of cranial injury and high PATI were predicting factors
for mortality in PAT. These factors can further help to
prevent mortality. Improvements of conditions such as,
rapid transport of major trauma victims, blood bank ser-
vices, education of paramedical personnel, and other
trauma care systems would result in a significant reduc-
tion in patient mortality within the first hours after
injury.
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M. Aldemir
Dicle Universitesi, Tıp Fakültesi
. .
II.LK ve ACIL YARDIM ABD.
TUR- 21280, Diyarbakır, Turkey.
Tel. : +90 412 248 8155.
Fax : +90 412 248 8440.
E-mail : maldemir21@hotmail.com