Combined Head And Abdominal Blunt Trauma In The

Hemodynamically Unstable Patient: What Takes Priority?

Dibacakan Oleh:
Hamid Silitonga

Pembimbing:
Dr. Mahyudanil, SpBS (K)
BACKGROUND
To determine whether rare situations requiring craniotomy prior to
laparotomy can be identified on admission with simple clinical
parameters.
We hypothesized that hypotension is rarely associated with the need of a
combined procedure, especially in patients with mildly depressed
consciousness
Introduction
• Severe traumatic brain injuries and abdominal bleed-
ing is the most common cause of death due to hemorrhage.
• The combination of severe blunt head trauma and abdominal
bleeding is associated with a very high mortality
• The need, timing, and sequence of craniotomy or laparotomy in the
hemodynamically unstable patient or in austere environments, can
challenge the judgment of the trauma team
• Exploratory laparotomy to stop bleeding and craniotomy to drain
intracranial hematomas or reduce intracranial pressure are time
sensitive procedures, which can determine survival and functional
outcomes.
• In patients with sustained severe hypotension, who require
an immediate laparotomy, it is crucial to clinically identify those
who might benefit from a combined craniotomy.
• In these cases, a CT scan of the head should be pursued before
laparotomy to initiate without any major delay, the potentially
lifesaving neurosurgical procedure
• We hypothesized that in hemodynarnically unstable patients with
combined head and abdominal trauma, clinical parameters available
on admission could predict which patients would require a subsequent
craniotomy
Material and methods
• This retrospective cohort study was performed using the
National Trauma Data Bank (NTDB) from January 2007 to December
2016.
• Trauma patients ( ≥ 16 years) with combined severe head
and abdominal injury, both defined as Abbreviated Injury
Scale (AIS) score of 3 or higher, were included
• Patients with penetrating trauma were excluded, death on arrival, and
those with missing hospital disposition or missing length of stay.
• Missing time to laparotomy or missing time to craniotomy were
excluded and only those with a laparotomy within 24 hours of admission
were considered for final analysis.
• Data collection included time of arrival, age, sex, mechanism of injury
(motor vehicle collision, motorcycle collision, auto versus pedestrian,
fall, other), facility and transfer information, vital signs (blood
pressure, heart rate), and Glasgow Coma Scale (GCS) score on
admission, diagnosis, and procedure codes.
• Hypotension was defined as blood pressure less than 90 mm Hg, and
tachycardia was defined as heart rate greater than 120 beats per
minute.
RESULTS
• A total of 25,585 adult trauma patients with combined severe head and
abdominal blunt trauma were identified.
• We excluded 15,658 patients without a laparotomy and 789 patients
with a laparotomy after 24 hours of admission
Figure 1. Flowchart: Inclusion, exclusion criteria. Age is reported in
years. * Of these 4,667 patients were hypotensive. There were 2,421
(51.9%) of the hypotensive patients who underwent only a
laparotomy, 54 (1.2%) only a craniotomy, and 79 (1.7%) needed a
combined procedure within 24 hours of admission. EX-LAP,
explorative laparotomy; CRANI, craniotomy/craniectom
DISCUSSION
• The combination of these two conditions is highly lethal
• In patients with severe hypotension not responding to appropriate fluid
resuscitation, delaying abdominal hemorrhage control to obtain a head
CT scan can be catastrophic
• On the other hand, delaying the head CT scan and evacuation of a
treatable intracranial pathology while controlling the abdominal
bleeding may be equally catastrophic.
• Reducing time to laparotomy or craniotomy is a well-known factor,
which improves survival
• Early identification of this subgroup of patients and simultaneous
laparotomy/ craniotomy can be lifesaving.
• Wisner et al., in 1993, retrospectively analyzed 800 trauma patients, Fifty-
two patients (6.5%) underwent a craniotomy, and 40 (5.0%) required a
laparotomy. Only 3 (0.4%) patients needed both laparotomy and craniotomy.
• Predictor of the need for a craniotomy, based on emergency department
evaluation, was indicated by the presence of lateralizing neurologic sings.
• The authors recommended to proceed with a laparotomy if abdominal
hemorrhage was suggested by diagnostic tests because of the relatively rare
incidence of a combined head and abdominal trauma, requiring intervention
• Winchell et al., in 1995, retrospectively studied 212 hypotensive (SBP < 100 mm Hg)
blunt trauma patients with suspected head injury. Overall, 40 general surgical
operations (19%) and 16 craniotomies (8%) were performed. Only 5 (2%) patients
required both general surgical intervention and craniotomy. Overall, the craniotomy
rate was 19% in patients with GCS score of 3 to 7, 9% in patients with GCS score of 8
to 12 , and 2% in patients with GCS score of 13 to 15.
• No patients, who responded to resuscitation with systolic blood pressure of more than
100 mm Hg at 10 and 20 minutes after admission experienced instability while
undergoing CT scan of the head. Therefore, the authors advocated to perform a CT
scan of the head before general surgical operation if the patient responds to initial fluid
resuscitation.
• Of the five patients with a combined procedure, one patient had a GCS score of 3 to 6,
three patients had a GCS score of 8 to 12, and one patient had a GCS score of 13 to 15.
• Another study by Thomason, in 1993, evaluated 734 blunt trauma
patients with hypotension (SBP <90 mm Hg). Serious head injury
(AIS head score, ~ 3) was present in 40%, and the rate of emergency
craniotomy was reported with 2.5%. Twenty-one percent of the
patients underwent urgent laparotomy, and only six (0.8%) patients
needed a combined procedure.
• All patients required a craniotomy had a GCS score of 8 or lower.
Considering the 8.5 times higher urgent laparotomy than craniotomy
rate, the authors concluded that the much higher emergent laparotomy
rate may be used in prioritizing the management strategy.
• In modem trauma centers, most of the problems related to the timing
and prioritization of the head CT scan or laparotomy, have been
addressed with the inclusion of CT scanners in the shock-room, which
results in faster completion of the diagnostic workout.
Conclusion
• The need for craniotomy in patients with severe combined head and
abdominal injury requiring laparotomy is very low.
• In hypotensive patients requiring laparotomy, a GCS 7-8 was the
strongest independent predictor available on patient's arrival indicating
the need for craniotomy.
• Appropriate resuscitation measures to perform a CT scan of the head
prior to the laparotomy should be considered in these patients.
• In hypotensive patients with a GCS score higher than 8, it may be safer
to proceed with a laparotomy first and address the head with a CT scan
at a later stage.
Terima Kasih