Point of care cardiac ultrasound applications in the emergency department and intensive care unit–a review. Although prognosis for these injuries is extremely variable, early evidence of DAI is associated with a poor outcome. Injuries of the hepatic ducts are almost impossible to satisfactorily repair under emergent circumstances. Deutsche Gesellschaft für Unfallchirurgie. Management requires frequent operative or percutaneous drainage of abscesses, control of fistulas, and prolonged nutritional support.  DB, Moore Messerstiche oder Schüsse Ursachen einer perforierenden Verletzung sind. This acts as a flutter valve, permitting effective ventilation on inspiration while allowing accumulated air to escape from the pleural space on the untaped side, so that a tension pneumothorax is prevented. Even when the initial chest tube output is 1.5 L, if the output ceases and the lung is re-expanded, the patient may be managed nonoperatively if hemodynamically stable. The distal internal carotid artery is exposed by dividing the ansa cervicalis, which permits mobilization of the hypoglossal nerve. Splenic injury is not uncommon in abdominal trauma, making up about one-third of all blunt abdominal injuries in children. 5. Eine chirurgische Versorgung von Verletzungen in diesem Bereich erfordert eine vollständige vaskuläre Ausklemmung der Leberperfusion. Vaughn A lateral canthotomy may be needed to relieve periorbital pressure. Abdominal trauma is still a challenge in clinical practice.  et al.. Liver transplantation for severe hepatic trauma: experience from a single center. In high-risk patients, removable inferior vena caval filters should be considered if there are prolonged contraindications to administration of LMWH. Blunt abdominal trauma + hypotension with positive FAST scan, positive diagnostic peritoneal lavage (DPL) or peritonism. 7-11). 66.94.110.250 Shock, transfusion, and pneumonectomy.  JW.  BA, Moore The current options are loop ileostomy and sigmoid loop colostomy. 7-74).  S. The pregnant motor vehicle accident casualty: adherence to basic workup and admission guidelines.  P, Murthi With complete mobilization, the spleen can reach the level of the abdominal incision. hepatoduodenale gedrosselt werden (so genanntes Pringle-Manöver). Durante la revisión primaria Circulación Compromiso concomitante Lesión.  A, Melloni  CC, Moore Trauma, or injury, is defined as cellular disruption caused by environmental energy that is beyond the body’s resilience, which is compounded by cell death due to ischemia/reperfusion. A rule of thumb to consider for secondary access is placement of femoral access for thoracic trauma and jugular or subclavian access for abdominal trauma. Als Spätfolge nach Pankreastrauma ist mit der Bildung von Pankreaspseudozysten zu rechnen, die sich in über der Hälfte der Fälle jedoch spontan zurückbilden. During laparotomy for blunt trauma, expanding or pulsatile perinephric hematomas should be explored. Patients with ongoing hemodynamic instability, whether “nonresponders” or “transient responders,” require prompt intervention; one must consider the four categories of shock that may represent the underlying pathophysiology: hemorrhagic, cardiogenic, neurogenic, and septic. Zone II is located between the clavicles and the angle of the mandible. Additionally, intubated patients, patients with distracting injuries, or another identified spine fracture should undergo CT imaging. 7,8. Duodenopankreatektomie) vorgenommen werden.  C Patients with injured extremities often require a multidisciplinary approach with involvement of trauma, orthopedic, and plastic surgeons to address vascular injuries, fractures, soft tissue injuries, and compartment syndromes. Han LO, Zhou LH, Cheng SJ, Song C, Song CF. Entries highlighted in bold are key references.  RJ. Adequate ventilation is critical, because oxygen consumption in infants and young children is twice that in adults; onset of hypoxemia, followed by cardiac arrest, may be precipitous. Sorgfältige Begutachtung aller Organe (inkl.  C, McClure Patients with trauma-induced coagulopathy (TIC) are at risk for massive transfusion and need to be identified early. Supplemental oxygen is always warranted in the trauma patient but is particularly critical in the injured pregnant patient, because the oxygen dissociation curve is shifted to the left for the fetus compared to the mother (i.e., small changes in maternal oxygenation result in larger changes for the fetus because the fetus is operating in the steep portions of the dissociation curve). 7-4). Although policies vary at individual institutions, most agree patients in extremis with need for Foley catheter placement should undergo one attempt at catheterization; if the catheter does not pass easily, a percutaneous suprapubic cystostomy should be considered. Coagulation abnormalities in the trauma patient: the role of point-of-care thromboelastography. Motor function, pain, and temperature sensation are preserved in the lower extremities but diminished in the upper extremities. Injuries that do not penetrate the peritoneal cavity do not require further evaluation, and the patient may be discharged from the ED. In most patients a short PTFE graft (usually 18 mm in diameter) is placed using a running 3-0 polypropylene suture. Life-threatening injuries must be identified (Table 7-1) and treated before being distracted by the secondary survey. In general, ligation from the celiac axis to the level of the common hepatic artery at the gastroduodenal arterial branch is tolerated due to the extensive collaterals, but the proper hepatic artery should be repaired. Thoracic injuries are second only to brain injuries as the main cause of death according to the National Pediatric Trauma Registry; however, the overall mortality rate of 15% correlates with the levels in many adult studies. The abdominal compartment syndrome may be primary (i.e., due to the injury of abdominal organs, bleeding, and packing) or secondary (i.e., due to reperfusion visceral edema, retroperitoneal edema, and ascites). Penetrating wounds to the superior mesenteric artery (SMA) are typically encountered upon exploration for a gunshot wound, with “black bowel” and associated supramesocolic hematoma being pathognomonic. Thomas G. Orr Memorial Lecture.Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. During diagnostic evaluation, type O RBCs (O-negative for women of childbearing age) and thawed AB plasma should be administered at a ratio of 2:1. 33). Als Basisdiagnostik dient die Sonographie zum Nachweis freier intraabdominaler Flüssigkeit. Google Scholar, Aufmolk M, Nast-Kolbe D (2001) Abdominaltrauma. Patients with distal ductal disruption undergo distal pancreatectomy, preferably with splenic preservation. The SMV should be repaired optimally, but >80% of patients will survive following ligation.  EL, Burlew  EE, Ilke The utility of RT has been debated for decades.  S, Keim Gonzalez Any episode of hypotension (defined as a SBP <90 mm Hg) is assumed to be caused by hemorrhage until proven otherwise. Patients in shock have a lower tolerance to warm ischemia, and an occluded extremity is prone to small vessel thrombosis. Over 90% of blunt renal injuries are treated nonoperatively. IMV = inferior mesenteric vein; IVC = inferior vena cava; SMV = superior mesenteric vein. B. Bei tieferen Gewebeverletzungen kann zusätzlich eine Ausräumung von Nekrosen und des Hämatoms notwendig werden (Grad II). Grade V: vessel transection. Ultrasound (FAST) of the abdomen should evaluate the four windows (pericardial, right and left upper quadrant, and bladder) and additionally assess FHTs, fetal movement, and sufficiency of amniotic fluid. Gastric wounds can be oversewn with a running single-layer suture line or closed with a stapler. The injury track is thus filleted open, which allows direct access to the bleeding vessels and leaking bronchi. 7-8). Volume restoration is based on the child’s weight; two to three boluses of 20 mL/kg of crystalloid is appropriate. Supracolic injuries (aorta, celiac axis, proximal superior mesenteric artery [SMA], and left renal arteries) are best approached a left medial visceral rotation (Fig. All blunt trauma patients should be assumed to have cervical spine injuries until proven otherwise. The management algorithm for hemodynamically stable patients is based on the presenting symptoms and anatomic location of injury, with the neck being divided into three distinct zones (Fig. auf eine bildgebende Diagnostik verzichtet und unmittelbar laparotomiert werden!  F Penetrating injuries in this patient population also carry a high risk.   •  Accessibility Evaluation of the head includes examination for injuries to the scalp, eyes, ears, nose, mouth, facial bones, and intracranial structures.  SW, Soto These patients are identified by bedside ultrasound, and the morbidity of a laparotomy is avoided.  GJ, Hoyt DPL can be performed in pregnant women via a supraumbilical, open technique. Some injuries of the pancreatic head do not involve either the pancreatic or common bile duct; if no clear ductal injury is present, drains are placed.  CR, Demarest Acute myocardial infarction may be the cause of a motor vehicle collision or other trauma in older patients. Unter dem Abdominaltrauma versteht man Verletzungen der Organe im Abdomen, die durch eine Gewalteinwirkung auf die Leibeswand hervorgerufen wurden. 7-45).  C Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. Aside from hemorrhage and hepatic necrosis, additional complications after significant hepatic trauma include bilomas, arterial pseudoaneurysms, and biliary fistulas (Fig. In patients with gunshot wounds to the chest or abdomen, a chest and abdominal film, with radiopaque markers at the wound sites, should be obtained to determine the trajectory of the bullet or location of a retained fragment. Paradoxical movement of this free-floating segment of chest wall is usually evident in patients with spontaneous ventilation, due to the negative intrapleural pressure of inspiration. Vor Durchführung des Pringle-Manövers müssen Begleitverletzungen der Milz und des Pankreas ausgeschlossen werden, um stauungsbedingte Blutungskomplikationen zu vermeiden.  et al.. Inflammation and the Host Response to Injury, a large-scale collaborative project: patient-oriented research core—standard operating procedures for clinical care. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. Early in the course of tamponade, blood pressure and cardiac output will transiently improve with fluid administration due to increased central venous pressure. However, death rate underestimates the magnitude of the societal toll. In addition to operative intervention, postinjury care directed at limiting secondary injury to the brain is critical. Chirurg. Virtually all transections and any injury associated with significant tissue loss will require a Roux-en-Y choledochojejunostomy.103 The anastomosis is performed using a single-layer interrupted technique with 5-0 monofilament absorbable suture. One or more branches of the external carotid artery usually must be ligated to gain access to the skull. Liquid and clotted blood are evacuated with multiple laparotomy pads to identify the major source(s) of active bleeding. First, outcomes are worse in this age group than in their younger counterparts. Brown-Séquard syndrome is usually the result of a penetrating injury in which one-half of the spinal cord is transected.  K, Ives Fogarty thromboembolectomy should be done proximally and distally to optimize collateral blood flow.  PC, Kufera Administration of atropine before rapid-sequence intubation will prevent bradycardia. Pulmonary tractotomy divides the pulmonary parenchyma using either a transection/anastomosis (TA) or gastrointestinal anastomosis (GIA) stapler. If there is doubt, however, it is always safer to explore the abdomen. All potentially seriously injured patients should undergo digital rectal examination to evaluate for sphincter tone, presence of blood, rectal perforation, or a high-riding prostate; this is particularly critical in patients with suspected spinal cord injury, pelvic fracture, or transpelvic gunshot wounds.  JF, Roberts A. Full-thickness loss of the chest wall results in an open pneumothorax. With the gravid uterus enlarged, DPL should be performed in a supraumbilical site with the catheter directed cephalad. Vertebral artery injuries due to penetrating trauma are difficult to control operatively because of the artery’s protected location within the foramen transversarium. 7-44). Roberts JL, Dalen K, Bosanko CM, Jafir SZ. Indications for immediate operative intervention are deterioration in neurologic function and fractures or dislocations with incomplete deficit. Howdieshell Bethesda, MD 20894, Web Policies Resuscitation to values of >500 mL/min per square meter for the oxygen delivery index and >3.8 L/min per square meter for the cardiac index are the goals.133 Pulmonary artery catheters also enable the physician to monitor response to vasoactive agents. Vasoparalysis with verapamil, nitroglycerin, and papaverine may be used to treat vasoconstriction (Table 7-11). Patients with pancreatic contusions (defined as injuries that leave the ductal system intact) can be treated nonoperatively or with closed suction drainage if undergoing laparotomy for other indications. The aorta, subclavian artery, and brachial artery, however, are difficult to mobilize for additional length. The first step is division of the ansa cervicalis to facilitate mobilization of the hypoglossal nerve. “Normal” values for vital signs should not necessarily make one feel more secure about the child’s volume status. Fractures documented by CT scan are usually repaired. sources of bleeding are typically spleen, liver, pelvis, retroperitoneal or gastrointestinal haemorrhage. B. B. rezidivierende Pyelonephritiden, Pneumonie, Hepatitis usw.) Such a delay is particularly troublesome for patients who have lost two blood volumes while waiting for the test results to return. Pancreatic injuries, regardless of location, are packed and the evaluation of ductal integrity postponed. Although correction of metabolic acidosis is desirable, how quickly this should be accomplished requires careful consideration. However, physical examination and ultrasound can rapidly identify patients requiring emergent laparotomy.  MJ, Tsai  RJ, Martin Zone I is inferior to the clavicles encompassing the thoracic outlet structures, zone II is between the thoracic outlet and the angle of the mandible, and zone III is above the angle of the mandible. If bleeding can be controlled with perihepatic packing, the packing should be left undisturbed and the patient observed in the SICU.  WL, Moore The most common intra-abdominal complications are anastomotic failure and abscess. Stürze oder Verkehrsunfälle. In penetrating injuries, pulmonary tractotomy is used to divide the parenchyma (Fig.  JW, Veldenz PMC  et al.. If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. In Europa überwiegt es bei weitem die penetrierenden Bauchverletzungen. Deterioration in mental status may be subtle and may not progress in a predictable fashion. In patients with any hemodynamic disturbance, a pericardial drain is placed using ultrasound guidance (Fig. If the patient has persistent fever or leukocytosis, however, chest CT is done to evaluate for an evolving abscess, because pneumatoceles may become infected. Kozar 1996 Sep;41(3):484-7 Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 , Lübeck, Deutschland, P. Hildebrand, C. Hindel , U.J. Bei stumpfem Abdominaltrauma ist die Entscheidung für oder gegen eine Laparotomie von der Klinik abhängig. 26). 2006 Nov;77(11):1007-13. doi: 10.1007/s00104-006-1245-9. In the scenario of tangential high energy GSWs, however, it is possible to sustain a transmitted intraperitoneal hollow visceral injury due to a blast insult. Damit lassen sich z.B. IV. Lillemoe ¿Buscas más material de apoyo? Nachfolgend sollen die typischen Organverletzungen sowie die verletzungsgerechten Therapiekonzepte dargestellt werden. auch einfache Röntgenaufnahme ausreichend, Stichverletzungen mit unklarem Verletzungsausmaß, Bei kleineren intraabdominellen Verletzungen ggf.  JB. A 6.0 endotracheal tube is inserted after digital confirmation of airway access.  et al..  K, Velopulos Bei ausgedehnten Verletzungen bzw. 1999 Nov;70(11):1255-68 Compartment syndromes, which can occur anywhere in the extremities, involve an acute increase in pressure inside a closed space, which impairs blood flow to the structures within. Clancy  et al.. Ultrasound is an effective triage tool to evaluate blunt abdominal trauma in the pediatric population. C. The continuous suture is tied near the antimesenteric border. B. All injured patients should receive supplemental oxygen and be monitored by pulse oximetry. Gunshot wounds to the abdomen are associated with a 70% injury rate to the uterus and 35% mortality rate of the fetus. Demetriades Surgery, ranging from partial resection to anatomic lobectomy, is indicated for unresolving complex pneumatoceles or infected lesions refractory to antibiotic therapy and drainage. Abdominal trauma is an injury to the abdomen.  HJ This is essential, because efforts to restore cardiovascular integrity will be futile unless the oxygen content of the blood is adequate.  et al.. Richardson  A, Kenny-Moynihan Traction must be maintained on both ends of the suture to prevent loosening and leakage of blood. Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years and is the third most common cause of death regardless of age.1 It is also the leading cause of years of productive life lost. Unabdingbare Voraussetzung der konservativen Therapie ist jedoch die engmaschige klinische, laborchemische und sonographische Kontrolle des Patienten für 1–2 Wochen. Another clinical challenge is the open pelvic fracture. If hemorrhage occurs from these injuries, compartment syndrome and limb loss may occur. This lesion is characterized by the ipsilateral loss of motor function, proprioception, and vibratory sensation, whereas pain and temperature sensation are lost on the contralateral side.  MA. Howes N, Walker T, Allorto NL, Oosthuizen GV, Clarke DL. Stichverletzungen im Bauchraum sind eine häufige Ursache für perforierende Abdominaltraumata. Ein hypovolämischer Schock entsteht bei ausgeprägten Blutverlusten. American journal of roentgenology. A good question to ask awake patients is whether their bite feels normal to them; abnormal dental closure suggests malalignment of facial bones and a possibility for a mandible or maxillary fracture. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. During exploration of the lesser sac, visualization and palpation of the pancreas is done to exclude injury. Davenport For patients with stab wounds, the length and type of object is helpful. Through a process of self-study and mindful body awareness, you can start to . The typical case is a patient with a penetrating thoracic injury who is hemodynamically stable but experiences cardiac arrest after being intubated and placed on positive pressure ventilation. If the trachea is completely transected, a nonpenetrating clamp should be placed on the distal aspect to prevent tracheal retraction into the mediastinum; this is particularly important before placement of the endotracheal tube. S30.-. Bei schwerer hämodynamischer Instabilität aufgrund einer (vermuteten) intraabdominellen Verletzung muss ggf. Death is due to right heart failure and increased pulmonary vascular resistance.  DD. Although the trap door procedure is appropriate after resuscitative thoracotomy, the proximal left subclavian artery can be accessed more easily via a sternotomy with a supraclavicular extension. In general, outcome after pelvic vascular injuries is related to (a) the technical success of the vascular reconstruction and (b) associated soft tissue and nerve injuries. Survivable penetrating cardiac injuries consist of wounds that can be repaired operatively; most are stab wounds. Blunt injury to the carotid or vertebral arteries may cause dissection, thrombosis, or pseudoaneurysm, typically in the surgically inaccessible distal internal carotid (Fig. B. J Trauma 2009;66(4):1040–1044. Early monitoring of arterial blood gas values will identify occult shock. Die posttraumatische Belastungsstörung wird auch posttraumatisches Belastungssyndrom genannt, da sie manchmal viele verschiedene Symptome umfasst. Tube thoracostomy is performed in the midaxillary line at the fourth or fifth intercostal space (inframammary crease) to avoid iatrogenic injury to the liver or spleen. Temporary control of hemorrhage, and at times definitive repair, may be accomplished with skin staples for left ventricular lacerations; the myocardial edges of the laceration must coapt in diastole for stapling to be technically feasible. Alternatively, open ends of the bowel may be ligated using umbilical tapes to limit spillage. Although early enteral nutrition is the goal, evidence of bowel function should be apparent before advancing to goal tube feedings. Minino Fractures of tooth-bearing bone are considered open fractures and require antibiotic therapy and semiurgent repair to preserve the airway as well as the functional integrity of the occlusion (bite) and the aesthetics of the face. 9 Edición. Unfallchirurg 72: 861–875, Article  Please enable it to take advantage of the complete set of features! A curved hemostat is a useful adjunct to create the curve. Motor vehicle collisions and falls are the leading causes of injury, accounting for 70% of cases. The use of pyloric exclusion in the management of severe duodenal injuries. Fatty deposition in the myocardium, resulting in: (a) Progressive stiffening and loss of elasticity, (b) Diminished stroke volume, systolic contraction, and diastolic relaxation, Decrease in cardiac output of 0.5% per year, Atherosclerotic disease that limits cardiac response to stress, Thickening and calcification of the cardiac valves, which results in valvular incompetence, Progressive loss of alveolar size and surface area, (a) Increased risk of tearing of bridging veins with smaller injuries, (b) Accumulation of a significant amount of blood before symptoms occur, Decline in creatinine clearance by 80%–90%, Osteoporosis, which causes a greater susceptibility to fractures. Complications related to colorectal injuries include intra-abdominal abscess, fecal fistula, wound infection, and stomal complications. Seine Verletzungen sind aufgrund seiner retroperitonealen Lage unter den parenchymatösen Organverletzungen beim Bauchtrauma selten. BV = blood volume; CNS = central nervous system.  TR, Heffernan Zur initialen Überwachung einer konservativen Therapie nach Abdominaltrauma bietet sich die Aufnahme auf eine Intensiv- oder Intermediate-Care-Station an! If the bullet traverses the uterus and the fetus is viable, cesarean section should be performed. Regardless of the etiology, acute injuries are usually repaired through an abdominal approach to manage potential associated intraperitoneal visceral injury.  EE The pelvic hematoma often dissects the preperitoneal and paravesical space down to the presacral region, which facilitates packing; alternatively, blunt digital dissection opens the preperitoneal space for packing. (required - use a semicolon to separate multiple addresses).  TM, Spain Scores range from 3 (the lowest) to 15 (normal). A 6.0 endotracheal tube (maximum diameter in adults) is then advanced through the cricothyroid opening and sutured into place.  et al.. After penetrating trauma, a great vessel or pulmonary hilar vessel injury should be presumed. Abdominal Trauma, Penetrating answers are found in the 5-Minute Emergency Consult powered by Unbound Medicine.  et al.. Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? Als Ultima ratio kommt bei schwerster Leberzertrümmerung (Grad V–VI), wenn eine Blutungskontrolle durch die genannten Maßnahmen nicht zu erreichen ist, eine ein- oder zweiseitige Lebertransplantation in Frage, welche in Einzelfällen beschrieben wurde [1]. Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: Results results of 145 cases. Schema zum Behandlungskonzept der traumatischen Milzruptur. Because any of these clinical symptoms of abdominal compartment syndrome may be attributed to the primary injury, a heightened awareness of this syndrome must be maintained. The https:// ensures that you are connecting to the AWMF-Leitlinie Nr. BioGlue hemostasis of penetrating cardiac wounds in proximity to the left anterior descending coronary artery. Seriously injured patients must have all of their clothing removed to avoid overlooking limb- or life-threatening injuries.  JW. El traumatismo abdominal (traumatismo abdominal) se diferencia por causa de la siguiente manera: embotado trauma abdominal - la pared abdominal está intacta. For patients undergoing DPL evaluation, laboratory value cutoffs to rule out diaphragm injury are different from traditional values formerly used for abdominal stab wounds (see Table 7-6). Because the pericardium is not acutely distensible, the pressure in the pericardial sac will rise to match that of the injured chamber. Plasma albumin level decreases from a normal of around 4.3 g/dL to an average of 3.0 g/dL.  MO, McKenney  CC, Moore Ursachen stumpfer Verletzungen sind bspw.  DJ, Rosenfeld Pseudoaneurysms and biliary fistulas are rare complications in patients with hepatic injuries. 3.6.73.121 Priority-based strategy]. Air accumulation in the left ventricle impedes diastolic filling, and during systole air is pumped into the coronary arteries, disrupting coronary perfusion.  M. Pericardiocentesis in traumatic and nontraumatic cardiac tamponade. Alternatively, the duct can be ligated if the opposite lobe is normal and uninjured. The airway may be stabilized before incision of the membrane using a tracheostomy hook; the hook should be placed under the thyroid cartilage to elevate the airway.  MA, Shapiro Therefore, the majority of trauma centers advocate an initial aggressive approach with re-evaluation at the 72-hour mark to determine subsequent care. Todd B. 7-52). Gross hematuria demands evaluation of the genitourinary system for injury. The renal arteries and veins are uniquely susceptible to traction injury caused by blunt trauma.  J Surg Gynecol Obstet 173: 179–182, Feliciano DV, Jordan GL, Bitondo CG et al. B. Although the optimal ratio is yet to be determined, current scientific evidence indicates a presumptive 1:2 red cell:plasma ratio in patients at risk for massive transfusion (10 units of PRBCs in 6 hours).57,58,59,60 Because complete typing and cross-matching takes up to 45 minutes, patients requiring emergent transfusions are given type O, type-specific, or biologically compatible RBCs. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral. Bei Verletzungen der Hohlorgane, beispielsweise des Darmes, kann im Verlauf eine Entzündung der Bauchhöhle (Peritonitis) entstehen, die ebenfalls lebensbedrohlich werden kann, wenn sie zur Sepsis führt. The only absolute contraindication to nonoperative management is hemodynamic instability. During evaluation in the ED, the primary and secondary surveys commence, with mindfulness that the mother always receives priority while conditions are still optimized for the fetus.129 This management includes provision of supplemental oxygen (to prevent maternal and fetal hypoxia), aggressive fluid resuscitation (the hypervolemia of pregnancy may mask signs of shock), and placement of the patient in the left lateral decubitus position (or tilting of the backboard to the left) to avoid caval compression. After delineation of the injury, the chest should be evacuated of all blood and particulate matter, and thoracostomy tube placed if not previously done. - 173.236.137.254. B.  KL. Reference article, Radiopaedia.org (Accessed on 10 Jan 2023) https://doi.org/10.53347/rID-51343, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":51343,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/abdominal-trauma/questions/1625?lang=us"}, Case 4: renal trauma: AAST grade V injury, Case 8: traumatic intraperitoneal bladder rupture, Case 9: traumatic abdominal aortic injury, Case 12: traumatic retroperitoneal hemorrhage, Case 13: traumatic small bowel perforation, Case 14: renal trauma: AAST grade IV injury, proximal jejunum is most commonly affected by blunt trauma, followed by the duodenum and ascending colon at the ileocecal valve region. Those who attempt rapid-sequence induction must be thoroughly familiar with the procedure (see Chap.  et al.. A prospective observational multicenter study of the optimal management of patients with anterior abdominal stab wounds.  EE. All of these diagnoses should be made during the initial physical examination. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. Common combined injuries include clavicle/first rib fractures and subclavian artery injuries, dislocated shoulder/proximal humeral fractures and axillary artery injuries, supracondylar fractures/elbow dislocations and brachial artery injuries, femur fracture and superficial femoral artery injuries, and knee dislocation and popliteal vessel injuries. Additionally, elderly patients or those patients on antiplatelet agents or anticoagulation should be imaged despite a GCS of 15.31,32 For penetrating injuries, plain skull films may be helpful in the trauma bay to determine the trajectory of injury in hemodynamically unstable patients who cannot be transported for CT scan.  M, Jurkovich Art, Umfang und Frequenz der Labordiagnostik müssen an die konkrete klinische Situation angepasst werden! Abdominal trauma is an injury to abdomen; it may be blunt or . When the edges of such complex wounds cannot be fully approximated and hence the repair is not hemostatic, the authors have used surgical adhesive (BioGlue) to achieve hemostasis.88 Occasionally, interior structures of the heart may be damaged. Examples of such injuries include transection of both the intrapancreatic bile duct and the main pancreatic duct in the head of the pancreas, avulsion of the papilla of Vater from the duodenum, and destruction of the entire second portion of the duodenum.  AB, Marsh Operative intervention after blunt trauma is limited to renovascular injuries and destructive parenchymal injuries that result in hypotension. Fetal loss may be related to both maternal shock and direct injury to the uterus or fetal head. Bei instabilen Patient:innen wird auf diese Diagnostik jedoch zugunsten einer raschen Therapie verzichtet. 7-54).78 After identification of an injury, antithrombotics are administered if the patient does not have contraindications (intracranial hemorrhage, falling hemoglobin level with solid organ injury or pelvic fracture). Temporary abdominal closure and a second-look operation to evaluate bowel viability should be done. Jones The most common approach has been to measure SBP using Doppler ultrasonography and compare the value for the injured side with that for the uninjured side, termed the A-A index.47 If the pressures are within 10% of each other, a significant injury is unlikely and no further evaluation is performed. Diaz Callaham Injuries adjacent to coronary arteries should be repaired using horizontal mattress sutures, because use of running sutures results in coronary occlusion and distal infarction. Trauma Abdominal. For vessels <6 mm in diameter (e.g., internal carotid, brachial, superficial femoral, and popliteal arteries), autogenous saphenous vein from the contralateral groin should be used, because polytetrafluoroethylene (PTFE) grafts of <6 mm have a prohibitive rate of thrombosis. Dissection should be limited to the area of injury to prevent disruption of surrounding bronchial vasculature and ensuing ischemia and stricture. The role of selective angioembolization (SAE) in splenic salvage remains controversial with some groups advocated pre-emptive SAE.106 It is clear, however, that up to 20% of patients with splenic trauma warrant early splenectomy and that failure of nonoperative management often represents inappropriate patient selection.107,108 Unlike hepatic injuries, which usually rebleed within 48 hours, delayed hemorrhage or rupture of the spleen can occur up to weeks after injury. More than 1500 mL of blood in the pleural space is considered a massive hemothorax. A. (1992) Continuing evolution in the approach to severe liver trauma. Screening for blunt cardiac injury: An an Eastern Association for the Surgery of Trauma practice management guideline.  HE, Biffl  EE, Burch In a patient with multisystem trauma, enteral access via gastrostomy tube or needle-catheter jejunostomy should be considered. Wichtig ist ebenfalls die Bestimmung der Blutgruppe sowie eine BGA und ein Urinstatus. Additionally, in the OR a Bair Hugger¯ warmer (the upper body or lower body blanket) and heated inhalation via the ventilatory circuit is instituted. CAI = carotid artery injury; VAI = vertebral artery injury.  EE Liegen trotz unauffälliger Sonographie instabile Kreislaufverhältnisse vor, müssen weitere Untersuchungen angeschlossen werden, um weitere traumatische Ursachen (z.  SL However, delayed abdominal wall reconstruction was resource invasive, with considerable patient morbidity.  RP  et al.. Decompressive craniectomy for medical management for refractory intracranial hypertension: An AAST-MITC propensity score analysis. Prognosis for recovery is poor. In the aging population, perhaps due to osteoporosis, less force is required to cause a fracture. The ATLS format and basic tenets are followed throughout this chapter, with some modifications. B. Sternal transection requires individual ligation of both the proximal and distal internal mammary arteries on the undersurface of the sternum. Complications of blunt abdominal trauma include peritonitis, haemorrhagic shock, and death.  EE, Sauaia In patients with significant intra-abdominal fluid as the primary component of abdominal compartment syndrome, rather than bowel or retroperitoneal edema, decompression can be accomplished effectively via a percutaneous drain. It is important, therefore, to limit radiographs to those that are essential and to shield the pelvis with a lead apron when possible.  EE, Moore Die explorative Laparatomie ist der Goldstandard in der operativen Therapie nach schwerem Abdominaltrauma!  et al.. Hildebrando Ruiz Cisneros, Carlos Huayhualla Sauñe. Current advances in intraosseous infusion - a systematic review. descending colon is only rarely involved. Scalp lacerations through the galea aponeurotica tend to bleed profusely; these can be temporarily controlled with skin staples, Raney clips, or a large full-thickness continuous running nylon stitch. El-Menyar A, Abdelrahman H, Al-Thani H, Zarour A, Parchani A, Peralta R, Latifi R. J Trauma Manag Outcomes. Interposition grafts are used when end-to-end anastomosis cannot be accomplished without tension despite mobilization. Concurrent pulmonary contusion is noted in up to 35% of patients, and pneumonia complicates the injuries in 10% to 30% of patients with rib fractures, not surprisingly leading to longer ICU stays.135,136 Additionally, mortality increases linearly with the number of rib fractures. As discussed later in “Damage Control Surgery,” options include intraparenchymal tamponade with a Foley catheter or balloon occlusion (see Fig. Presence of a hemothorax in this age group may be particularly problematic, because the child’s chest may contain his or her entire blood volume. Presentation Transcript. Heart and Thoracic Vascular Injury. Heart rate increases by 10 to 15 beats per minute during the first trimester and remains elevated until delivery. A child sustaining a blow to the epigastrium (e.g., hitting the handlebars during a bike accident) should be evaluated for a duodenal hematoma and/or a pancreatic transection. There are no pathognomonic ECG findings, and cardiac enzyme levels do not correlate with the risk of cardiac complications.23 Therefore, patients for whom there is high clinical suspicion of cardiac contusion and who are hemodynamically stable should be monitored for dysrhythmias for 24 hours by telemetry. Häufig wird zusätzlich ein Computertomogramm des Abdomens angefertigt. In children older than 11 years, standard cricothyroidotomy is performed. Perforado trauma abdominal - debido a heridas por .  Jr., Aulino  et al..  FD, Dietz Because hemorrhage from hepatic injuries often is treated without isolating individual bleeding vessels, arterial pseudoaneurysms may develop, with the potential for rupture. Lateral suture repair is preferred for arterial injuries with minimal loss of tissue.  D Patients with suspected associated perforation, suggested by clinical deterioration or imaging with retroperitoneal free air or contrast extravasation, should undergo operative exploration. Although this method is exquisitely sensitive for detecting intraperitoneal fluid of >250 mL, it does not reliably determine the source of hemorrhage nor grade solid organ injuries.44 Patients with fluid on FAST examination, considered a “positive FAST,” who do not have immediate indications for laparotomy and are hemodynamically stable undergo CT scanning to quantify their injuries. For extensive wounds, presacral drains are inserted through a perianal incision (box) and advanced along Waldeyer’s fascia (dashed line). Median sternotomy with cervical extension is used for rapid exposure in patients with presumed proximal subclavian, innominate, or proximal carotid artery injuries. The primary objectives of damage control laparotomy are to control bleeding and limit gastrointestinal spillage. MacKenzie Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. If the chest tube output is initially 20% of the patient’s blood volume (80 mL/kg) or is persistently >1 to 2 mL/kg per hour, thoracotomy should be considered. Open repair of the descending aorta is accomplished using partial left heart bypass.86 With the patient in a right lateral decubitus position, the patient’s hips and legs are rotated 45 degrees toward the supine position to gain access to the left groin for common femoral artery cannulation. Consequently a pregnant woman may lose 35% of her blood volume before exhibiting signs of shock.  DJ, Tiruta If the left subclavian artery is injured outside the thoracic outlet, vascular control can be obtained via the sternotomy and definitive repair done through the supraclavicular incision. Intra-abdominal abscesses are common and routinely managed with percutaneous drainage. Alternatively, complete pelvic vascular isolation (Fig. Therapeutic hypothermia for severe traumatic brain injury: a critically appraised topic.  J, et Homicides, suicides, and other causes are responsible for another 50,000 deaths each year. CT imaging of blunt traumatic bowel and mesenteric injuries. Moore The primary objectives of damage control laparotomy are to control bleeding and limit GI spillage.  PJ, Moore Duodenal injuries should be evaluated with a wide Kocher maneuver. For example, when an unrestrained driver sustains a frontal impact, the head strikes the windshield, the chest and upper abdomen hit the steering column, and the legs or knees contact the dashboard. Medicine (Baltimore) 2004;83(5):274–279. Ist der Patient kreislaufstabil, jedoch freie Flüssigkeit in der abdominalen Notfallsonographie nachweisbar, sollte eine CT-Untersuchung des Abdomens angeschlossen werden, um mögliche Verletzungen genauer klassifizieren und therapieren zu können (ggf. Do not assume that someone who was stabbed was not also assaulted; the patient may have a multitude of injuries and cannot be presumed to have only injuries associated with the more obvious penetrating mechanism. These are preferred because they are quick and easy to perform, and provide essentially total fecal diversion.  et al.. Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. Biffl For other injury mechanisms, critical information includes such things as height of a fall, surface impact, helmet use, and weight of an object by which the patient was crushed. Sondeen The first decision is whether the patient has a supracolic or an infracolic vascular injury. Bei der Versorgung von Schwangeren sollte insb. Rupture into a bile duct results in hemobilia, which is characterized by intermittent episodes of right upper quadrant pain, upper GI hemorrhage, and jaundice. Lässt sich hierbei eine operationspflichtige Verletzung ausschließen, ist ein konservativer Behandlungsversuch mit kontinuierlicher stationärer Überwachung möglich (Abb.  R, Shavit Kliegel Nasogastric tube evaluation of stomach contents for blood may suggest occult gastroduodenal injury or the errant path of the nasogastric tube on a chest film may indicate a left diaphragm injury. Mishelle Chavez. If access is needed to both pleural cavities, the original incision can be extended across the sternum with a Lebsche knife, into a “clamshell” thoracotomy (Fig. Mortality is directly affected by the timing of decompression, with 60% mortality in patients undergoing presumptive decompression, 70% mortality in patients with a delay in decompression, and nearly uniform mortality in those not undergoing decompression. Head CT should be performed to determine intracranial pathology, followed by skull radiography to diagnose skull fractures. Imaging children with abdominal trauma.  et al.. Delta V, principal direction of force, and restraint use contributions to motor vehicle crash mortality. 7-18), and a palpable fracture. Computed tomography (CT) scanning is the mainstay of evaluation in the remaining patients to more precisely identify the site and magnitude of injury. HHS Vulnerability Disclosure, Help In the case of hepatobiliary and splenic trauma the main challenge lies in the need to control life-threatening bleeding, while in pancreatic injuries the primary goal is the avoidance of septic complications.  M, Polterauer Ochsner Davis The facial vein, which marks the carotid bifurcation, is usually ligated for exposure of the internal carotid artery. When the suture is tied, tension is adequate when visible hemorrhage ceases or the liver blanches around the suture. In management of vascular trauma, controversy exists regarding the treatment of patients with soft signs of injury, particularly those with injuries in proximity to major vessels. Compartment syndrome is common, and presumptive four-compartment fasciotomies are warranted in patients with combined arterial and venous injury. Extraperitoneal ruptures are treated nonoperatively with bladder decompression for 2 weeks. Examination of the oral cavity includes inspection for open fractures, loose or fractured teeth, and sublingual hematomas. Flexible endoscopy for the diagnosis of esophageal trauma. III) können mittels temporärer Kompression, Parenchymnaht, Infrarot- oder Argonkoagulation sowie Kollagenvlies oder Fibrinkleber versorgt werden. Central cord syndrome typically occurs in older persons who experience hyperextension injuries. Surgical management and outcome of blunt major liver injuries: experience of damage control laparotomy with perihepatic packing in one trauma centre. The .gov means it’s official. Viscoelastic hemostatic assays (TEG and ROTEM) have been shown to be superior to traditional laboratory tests, and have been central to the evolving concept of goal-directed hemostasis.50 These conceptual changes have significantly improved survival of critically injured patients; they have been promoted and critically reviewed by academic trauma centers via forums such as the American College of Surgeons Committee on Trauma, the American Association for the Surgery of Trauma, the International Association of Trauma Surgery and Intensive Care, the Pan-American Trauma Congress, and other surgical organizations. Conversely, patients receiving cardiac medications such as beta blockers may not be capable of increasing their heart rate to compensate for hypovolemia. El traumatismo abdominal cerrado es una emergencia quirúrgica de primer orden. Because esophagoscopy can miss injuries following an apparent normal endoscopy, patients at risk should undergo soluble contrast esophagraphy followed by barium examination to look for extravasation of contrast to identify an injury.39 As with neck injuries, hemodynamically stable patients with transmediastinal gunshot wounds should undergo CT scanning to determine the path of the bullet; this identifies the vascular or visceral structures at risk for injury and directs angiography or endoscopy as appropriate. Morbidly obese patients and those over 55 years of age are at additional risk. Zudem spielt der Unfallmechanismus eine Rolle. Several options exist for treating injuries of the pancreatic body and tail. Injuries of the extrahepatic bile ducts are a challenge due to their small size and thin walls. Before 7-40). The anterior and lateral compartments are approached from a lateral incision, with identification of the fascial raphe between the two compartments. Some functional recovery usually occurs, but is often not a return to normal. Cardiac injuries may be temporarily controlled using a running 3-0 nonabsorbable polypropylene suture or skin staples. Orotracheal intubation is the preferred technique used to establish a definitive airway. Cátedra Cirugía Dr. González.  AB When renorrhaphy is undertaken, effective repair is assisted by attention to several key points: A. Vascular occlusion controls bleeding and permits adequate visualization. The principles of vascular repair techniques (discussed previously) apply to carotid injuries, and options for repair include end-to-end primary repair (often possible with mobilization of the common carotid), graft interposition, and transposition procedures.  P, Böhmig High energy auto-pedestrian victims should have their pelvis wrapped with a sheet until radiography can be done.  G In general, physician-supervised axial traction, via cervical tongs or the more commonly used halo vest, is used to reduce subluxations and stabilize the injury. Establishing a definitive airway (i.e., endotracheal intubation) is indicated in patients with apnea; inability to protect the airway due to altered mental status; impending airway compromise due to inhalation injury, hematoma, facial bleeding, soft tissue swelling, or aspiration; and inability to maintain oxygenation. DAI results from high-speed deceleration injury and represents direct axonal damage from shear effects. These patients mandate immediate identification of the source of hypotension with appropriate intervention to prevent a fatal outcome. In patients with open fractures the wound should be covered with povidoneiodine (Betadine)-soaked gauze and antibiotics administered. An oral airway or a nasal trumpet is also helpful in maintaining airway patency, although the former is not usually tolerated by an awake patient. Rarely, immediate amputation may be considered due to the severity of orthopedic and neurovascular injuries. https://accesssurgery.mhmedical.com/content.aspx?bookid=2576§ionid=210406250. Allis clamps are used to approximate the diaphragmatic edges, and the defect is closed with a running No. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. If an injury is suspected during operative exploration but is not clearly identified, methylene blue or indigo carmine is administered IV with observation for extravasation. This is particularly true if primary nerve transection is present in addition to fracture and arterial injury.126 Collaborative decision making by the trauma, orthopedic, and plastic/reconstructive team is essential. 3). Causes of blunt abdominal trauma include motor vehicle accidents (MVAs), motorcycle crashes (MCCs), pedestrian-automobile impacts, falls, and assaults. Similarly the left renal vein can usually be ligated adjacent to the IVC due to collateral decompression. Patients with a SBP <60 mm Hg warrant resuscitative thoracotomy (RT) with opening of the pericardium for rapid decompression and to address the injury. 1.  GC, Kaminski  C, Moore Vagotomy is not necessary because a risk of marginal ulceration has not been documented. Because donor availability will limit such procedures, hepatic transplantation for trauma will continue to be performed only in extraordinary circumstances. The PTFE graft is anastomosed end to side from the proximal undamaged aorta and anastomosed end-to-end to the innominate artery (Fig. In stable patients, spleen-preserving distal pancreatectomy should be performed.  KJ. Otherwise it is hidden from view.  C, Bilaniuk Tachycardia is often the earliest sign of ongoing blood loss, but the critical issue is change over time. 7-16).  GS, Fischer government site.  GJ. For example, patients in class II shock are tachycardic but they do not exhibit a reduction in blood pressure until over 1500 mL of blood loss, or class III shock. Der Traumamechanismus ist von essenzieller Bedeutung für die weiteren Diagnostik- und Therapieentscheidungen! Offene Wunde des Abdomens, der Lumbosakralgegend und des Beckens. Proximal control at the infrarenal aorta arrests the arterial bleeding and avoids splanchnic and renal ischemia; however, venous injuries are not controlled with aortic clamping. For proximal SMV injuries, digital compression for hemorrhage control is followed by attempted venorrhaphy; ligation is an option in a life-threatening situation, but the resultant bowel edema requires aggressive fluid resuscitation. Abdominal trauma is usually divided into blunt and penetrating trauma. Ausweichmöglichkeit aufgrund der hohen Beweglichkeit, Verletzung insb. Plain radiographs are used to evaluate fractures, whereas ligamentous injuries, particularly those of the knee and shoulder, can be imaged with magnetic resonance imaging.  EE, Offner Part of Springer Nature. Classic signs and symptoms of shock are tachycardia, hypotension, tachypnea, altered mental status, diaphoresis, and pallor(Table 7-4). If hemostasis is not adequate to expose the vessel proximal and distal to the injury, sponge sticks can be strategically placed on either side of the injury and carefully adjusted to improve hemostasis. Appropriate volume compensation for this albumin-rich fluid remains controversial, with regard to both the amount administered (replacement based on clinical indices vs. routine ½ mL replacement for every milliliter lost) as well as the type of replacement (crystalloid vs. colloid). 7-34). 7-65).115 If the duodenal repair breaks down, the resultant fistula is an end fistula, which is easier to manage and more likely to close than a lateral fistula. As in adults, CPP is monitored, and appropriate resuscitation is critical to prevent the secondary insults of hypoxemia and hypovolemia. Patients may have distended neck veins due to impedance of venous return, but the neck veins may be flat due to concurrent systemic hypovolemia. The venous cannula is inserted into the left superior pulmonary vein because it is less prone to tearing than the left atrium (LA). Experimental work suggests that an endogenous sealing clot of an injured artery may be disrupted at an SBP of >90 mm Hg28; thus, many believe that this should be the preoperative blood pressure target for patients with potential torso arterial injuries. Transection at the injury site with proximal ligation and distal salpingectomy is a more prudent approach. In the supine position, blood tracks along the entire posterior section of the chest and is most notable pushing the lung away from the chest wall. Although immediate needle thoracostomy decompression with a 14-gauge angiocatheter in the second intercostal space in the midclavicular line may be indicated in the field, tube thoracostomy should be performed immediately in the ED before a chest radiograph is obtained (Fig. Injury. Specific organ injury (e.g., hollow viscus injury—stomach, small and large bowel, bladder, and diaphragm laceration). Organ failure can occur over a wide range of recorded bladder pressures. Patients with an open abdomen lose between 500 and 2500 mL per day of abdominal effluent. Trauma, Fachgebiete: Das Ausmaß einer traumainduzierten Koagulopathie kann durch die standardisierten Bedingungen der Labordiagnostik (konstante Temperatur mit Puffersubstanzen und Calziumüberschuss) verschleiert werden! Small duodenal perforations or lacerations should be treated by primary repair using a running single-layer suture of 3-0 monofilament. A Crash Injury Research Engineering Network (CIREN) study. Die Klinik des Abdominaltrauma ist sehr variabel. (1989) Surgical management of severe liver trauma: a role for liver transplantation. Injury Severity Score is probably the best overall predictor of patient outcome in the elderly; however, for any given individual its sensitivity may not be precise, and there is a time delay in obtaining sufficient information to calculate the final score. Infant survival after cesarean section for trauma. Additional sources of morbidity include a concurrent but unrecognized iatrogenic injury to the pancreatic tail during rapid splenectomy resulting in pancreatic ascites or fistula, and a gastric perforation during short gastric ligation.  GB, Cameron Immediate stabilization of fractures or unstable joints is done in the ED using Hare traction, knee immobilizers, or plaster splints. The topic of nutrition is well covered in other chapters, but a few issues warrant mention. Such a finding should prompt imaging to rule out an associated extracranial cerebrovascular injury. Admission chest film may not show the full extent of the patient’s pulmonary parenchymal injury. Ist der Patient kreislaufstabil, ist eine konservative Therapie unter intensivmedizinischer Überwachung möglich. Polytrauma / Schwerverletzten-Behandlung. Hemorrhage from most major hepatic injuries can be controlled with effective perihepatic packing. The choice between percutaneous and operative therapy is based on the location, timing, and extent of the collection. Patients undergo standard posttrauma resuscitative SICU care, and the pelvic packs are removed within 48 hours, a time frame chosen empirically based on the authors’ experience with liver packing. Nutrition support in adult trauma patients. Cothren Generally, pledget support is used for the relatively thin-walled right ventricle.  GB Less than 1% of all injured patients sustain intrathoracic tracheobronchial injuries, and only a small number require operative intervention. The aim of this review is to identify the nutritional deficits or excesses associated with the major complications of reconstructive surgery, aesthetic surgery, and mini . C. Three standard surgical laparotomy pads are placed on each side of the bladder, deep within the preperitoneal space; the fascia is closed with an O polydioxanone monofilament suture and the skin with staples. As a rule, minimal evaluation is required before laparotomy for gunshot or shotgun wounds that penetrate the peritoneal cavity, because over 90% of patients have significant internal injuries.  V Ziel des Traumamanagement ist es, das Ausmaß und die Prognose des Abdominaltraumas rasch zu definieren, um die Prioritäten sowie die Reihenfolgen in Diagnostik und Therapie festzulegen. Fetal monitoring should be performed with a cardiotocographic device that measures both contractions and fetal heart tones (FHTs). The majority of pulmonary parenchymal injuries are suspected based upon identification of a pneumothorax; the vast majority is managed by tube thoracostomy. A centrifugal pump is used to provide flow rates of 2.5 to 4 L/min to maintain a distal perfusion pressure of >65 mm Hg.  M Inaba Injury to the major arteries and veins in the abdomen can be a technical challenge.117,118,119,120,121 Although penetrating trauma indiscriminately affects all blood vessels, blunt trauma most commonly involves renal vasculature and occasionally the abdominal aorta. Diagnostic laparoscopy may be preferred in patients with a positive chest radiograph (hemothorax or pneumothorax) or in those who would not tolerate a DPL. Furthermore, individuals in good physical condition with a resting pulse rate in the fifties may manifest a relative tachycardia in the nineties; although clinically significant, this does not meet the standard definition of tachycardia. N Engl J Med 317: 1559–1564, Treutner KH, Bertram P, Schumpelick V (1993) Prinzipien der Milzerhaltung beim stumpfen Bauchtrauma. 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