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Blunt abdominal trauma: changing patterns in diagnostic and treatment strategies

van der Vlies, C.H.

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Citation for published version (APA):van der Vlies, C. H. (2012). Blunt abdominal trauma: changing patterns in diagnostic and treatment strategies.

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Download date: 12 Mar 2020

4A seatbelt sign following a car accident: look for internal abdominal injury

Vincent M. de JongCornelis H. van der VliesJan LuitseMark A. MeierKees J. ponsenJ. Carel Goslings

Ned Tijdschr Geneeskd. 2010;154: A1950

Chapter 4

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abstract

We present three patients, a 55 year old man, a 69 year old woman and a 25 year old man, all

with seatbelt signs following a car accident. The 3 patients exhibited a range of injuries that

can all occur with blunt trauma, such as rib fractures. In one patient, however, the symptoms of

internal abdominal injury occurred several days after the accident. The presence of a seatbelt

sign is associated with an increased risk of internal abdominal injury. We therefore advise that

a computed tomography CT scan of the abdomen is made in patients who present with a

seatbelt sign, even if an abdominal ultrasound does not reveal any signs of injury.

Ladies and gentlemen,

A ‘seat belt sign’ consists of ecchymosis and excoriations of the abdominal wall caused by

compressive stress and the shear forces of the seat belt. This phenomenon was described for

the first time in 1962.1 Since the introduction of the three-point seat-belt, this type of injury can

also be found on the thorax and neck. The presence of a ‘seat belt sign’ should alert doctors to

be aware of the possibility of intra abdominal injury.

In this lecture we will present three patients with blunt abdominal injury who exhibited a ‘seat

belt sign ’ when physically examined. The management issues related to this physical diagnostic

finding will be discussed in this article.

Patient A, a 55 year old Polish man, was involved in a one-sided car accident as substitute driver.

The driver ran head-on into a tree. Immediately after the accident the patient was transported

to the trauma unit and evaluated according to the ATLS protocol where he was found to be

A,B,C-stable with a Glasgow Coma Score (D) of 14 (E4M6V4) after an obvious use of alcohol.

Physical examination (E) revealed a ‘seat belt sign’ on the abdomen (Figure 1). Except for a rib

fracture of the first left and right ribs, no abnormalities were found on radiological findings

(X-ray of the pelvis, ultrasound of the abdomen, CT scan of the brain, cervical spine, thorax [with

intravenous contrast]). The patient was admitted to the hospital for observation and on the

next day he was discharged after a ‘tertiary survey’ (a second complete physical examination

conducted with the aim of detecting any injuries which may have been missed earlier). After

8 days, the patient reported to the hospital with a swollen abdomen, nausea and vomiting.

On physical examination the patient appeared unwell; he had a distended abdomen without

peristalsis. Laboratory investigation revealed there were no infections.

A CT scan with an intravenous contrast of the abdomen revealed a caliber jump at the terminal

ileum, possibly caused by an internal herniation of the intestines caused by a tear in the mesen-

terium (Figure 2). An ischemic terminal ileum was encountered during explorative laparotomy

and, for that reason, an ileocecal resection was performed. A herniation was not detected. The

patient left hospital 10 days later in a good physical condition.

51

A seatbelt sign following a car accident: look for internal abdominal injury

Patient B, a 45 year old man drove into the back of a lorry after having fallen asleep. The patient

was evaluated A, B, C, D stable during assessment in the shock room in accordance with the

guidelines. Physical examination showed a ‘seat belt sign’ on the left side of the lower part of

the abdomen and a tender abdomen. The ultrasonography revealed free fl uid in the cavum

Douglasi, we therefore, decided to perform a CT scan of the abdomen with intravenous con-

trast. At the mesocolon of the sigmoid, extravasation of contrast fl uid was detected (Figure

3) and a sigmoid resection with primary anastomosis was executed. The postoperative period

went well and after 5 days the patient left hospital in a good condition.

figure 1. ‘Seatbelt Sign’ of the abdomen

caliber jump

figure 2. CT scan with intravenous contrast of the abdomen revealed a caliber jump at the terminal ileum, possibly caused by an internal herniation of the intestines caused by a tear in the mesenterium.

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52

figure 3. CT scan of the abdomen with intravenous contrast (venous phase) showed extravasation of contrast fluid at the mesocolon of the sigmoid.

NED TIJDSCHR GENEESKD. 2010;154:A1950 NED TIJDSCHR GENEESKD. 2010;154:A1950 3

KLIN

ISCH

E PR

AKTI

JK

FIGUUR 3 CT-scan met intraveneus contrast van het abdomen van patiënt b. Ter hoogte van het mesocolon van het sigmoïd is extravasatie van contrast (‘blush’)

zichtbaar.

M. psoas

wervellichaam LV

colon

extravasatie van contrast

FIGUUR 4 Frontale CT-scan met intraveneus contrast van de thorax en het abdomen van patiënt C, die na een auto-ongeval het ‘seatbelt sign’ (afdrukhematoom van

de autogordel) vertoonde. Tussen de A. colica sinistra en de V. mesenterica inferior bevindt zich een traumatische arterioveneuze fistel.

liver

fistulailiac a

stomach

inferior mesenteric vein

tery left colic arteriovenous iliac atery

atery

figure 4. CT scan showed a contrast extravasation localized near the left mammarian artery and a traumatic arteriovenous fistula between the left colic artery and the superior mesenteric vein.

53

A seatbelt sign following a car accident: look for internal abdominal injury

Patient C, a 69 year old woman, was involved in a car-accident. She was reviewed in the trauma

room following the ATLS criteria. On arrival the patient was A, B, C, D stable. During the physical

examination a seat belt sign was detected and the abdomen was slightly tender. An X-ray of the

thorax revealed a fracture of the fi rst rib on both sides and a hematothorax on the right side. When a

thorax drain was inserted, 200 ml of blood was evacuated. The ultrasound showed no abnormalities.

After preparation with Tavegil® and Dexamethason®, which were used because of an iodine

allergy, a CT of the thorax and abdomen with intravenous contrast was performed. These

revealed multiple rib fractures on both sides, with a drained hematothorax on the right, a

fracture of the sternum, and multiple fractures of the pelvis. Liquid was present near the duode-

num and in the retroperitoneum. Intra-abdominal blood and air were both absent. Moreover,

contrast extravasation was found in a localized area near the left mammarian artery and a trau-

matic arteriovenous fi stula was discovered between the left colic artery artery and the superior

mesenteric vein (Figure 4). Both were treated with angiography and embolization with coils

(Figures 5 a,b). The patient did not develop complications and 1 week after the accident she

was discharged from hospital in a good condition.

pyelum

ureter coilarteriovenous fistula

portal vein inferior mesenteric vein

catheter left colic artery

inferior mesenteric artery

catheter

figure 5. Angiography of the traumatic arteriovenous fi stula between left colic artery and superior mesenteric vein. Before (a) and after (b) treatment with coil embolisation.

Chapter 4

54

trauma mechanism

Blunt trauma to the abdomen accompanied by mesenterial injury arises from the mechanisms

of deceleration and compression. A wide spectrum of injuries, varying from contusions to

lacerations of the abdominal wall and the mesenterium, can occur. Even full blown devasculari-

sation of fragments of the intestines may be manifest.

ePiDemiology

The presence of a ‘seat belt sign’ is associated with a higher risk of intra-abdominal injury. The

prevalence of intra-abdominal injury in the presence of a ‘seat belt sign’ is 10 – 21% and 2% if a

seatbelt sign is not present.2, 3

High clinical suspicion*

FAST

CT scan

Observation

Blunt abdominal injury and hemodynamically stable patient

Negative Positive

No

Yes

Minimal Yes No

Observation

Intervention or operation

Observation or DPL

Intra-abdominal injury

• Abnormalities in physical examination of the abdomen, pelvis or lumbar spine Abnormal X-ray of pelvis, lumbar spine or chest Abnormal FAST Base excess < -3 Systolic blood pressure < 90 mm Hg Long bone fractures

figure 6. Flow chart of the diagnostic and treatment process in patients with blunt abdominal injury. Minimal: minimal free fluid intra-abdominal and/ or small tear in the mesenterium.

55

A seatbelt sign following a car accident: look for internal abdominal injury

Diagnostic

From the case histories described above, it appears that diagnosing intra-abdominal injury

on the basis of clinical and radiological presentation can be difficult. Physical examination can

offer some useful indications, but symptoms such as abdominal pain, a distended abdomen,

decreased peristalsis, hypotension or shock are present in only 13 – 64% of patients in the acute

phase.4

Making an ultrasound of the abdomen is a non-invasive, quick investigation, but it is only suit-

able for detecting free fluid. The sensitivity and specificity for the detection of a hemoperito-

neum by using an ultrasound are 26 and 96% respectively.5 The sensitivity for the identification

of an injury to a solid organ is even lower (40 – 50%).6 In the latter case a hemoperitoneum is

observed in 29 – 44%. In every trauma patient a screening ultrasound of the abdomen is per-

formed. A CT scan is executed if free fluid is present as it is a sign of possible organ injury. The

sensitivity and specificity of a CT scan is 82 and 99% respectively. A CT scan is recommended

if there is any clinical evidence of intra-abdominal injury, such as a ‘seat belt sign’. It is even

speculated that an ultrasound is redundant if a ‘seat belt sign’ is present as the seat belt sign

is usually indicative of more extensive injuries being present which cannot be detected with

the ultrasound (because of its low sensitivity). Therefore, the only correct course of action is to

perform a CT scan.7

treatment

An imperative indication for a laparotomy is the intra-abdominal presence of free air.

Patients with a limited amount of free fluid without (parenchymatous) organ injury, (judged on

the basis of a CT scan), or patients with minimal mesenterial damage can be treated conserva-

tively. A DPL (diagnostic peritoneal lavage) can be carried out on these patients to differentiate

between an injury to a hollow organ (intestine, gallbladder), an active bleeding or an injury to

the pancreas.8 Any deterioration in the condition of the patient is an indication that a new CT

scan or laparotomy should be performed. Extensive mesenterial injuries accompanied by a lot

of free fluid demands direct surgical intervention. In the case of the vascular injuries (Patient

C), an endovascular treatment performed by an intervention radiologist is preferable. Currently

this latter treatment is not available in every hospital but, because of the progress in interven-

tional radiology, this may change in the coming years. Because of the high sensitivity of a CT

scan, a cooperative patient who has a ‘seat belt sign’, and no indicative signs of injury on the CT

scan, can be safely discharged from hospital. Comprehensive information about any possible

complications is essential.9 If a general practitioner detects a ‘seat belt sign’ during the physical

examination of a patient who has had a car accident, this patient should be referred to hospital

Chapter 4

56

for additional investigations. The Flowchart (Figure 6) illustrates our strategy for the diagnostic

and therapeutic pathway.

Ladies and gentlemen, after the introduction of the obligation to wear a seat belt, the morbidity

and mortality rates of car accident related injuries have drastically declined.10 However, a new

phenomenon has now appeared: ‘the seat belt sign’. If a ‘seat belt sign’ is present, one should be

aware of the presence of intra-abdominal injury and therefore a CT scan should be performed

accessible.

57

A seatbelt sign following a car accident: look for internal abdominal injury

references

1. Garrett JW, Braunstein PW. The seat belt syndrome. J Trauma. 1962; 2: 220-38. 2. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased

incidence of abdominal injury. Am Surg. 1997; 63: 885-8. 3. Velmahos GC, Tatevossian R, Demetriades D. The „seat belt mark“ sign: a call for increased vigilance

among physicians treating victims of motor vehicle accidents. Am Surg. 1999; 65: 181-5. 4. Wotherspoon S, Chu K, Brown AF. Abdominal injury and the seat-belt sign. Emerg Med. 2001; 13: 61-5. 5. Shanmuganathan K, Mirvis SE, Sherbourne CD, Chiu WC, Rodriguez A. Hemoperitoneum as the sole

indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma. Radiology. 1999; 212: 423-30.

6. Chiu WC, Cushing BM, Rodriguez A, Ho SM, Mirvis SE, Shanmuganathan K et al. Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). J Trauma. 1997; 42: 617-23.

7. Stassen NA, Lukan JK, Carrillo EH, Spain DA, Richardson JD. Abdominal seat belt marks in the era of focused abdominal sonography for trauma. Arch Surg. 2002; 137: 718-22.

8. Menegaux F, Tresallet C, Gosgnach M, Nguyen-Thanh Q, Langeron O, Riou B. Diagnosis of bowel and mesenteric injuries in blunt abdominal trauma: a prospective study. Am J Emerg Med. 2006; 24: 19-24.

9. Stuhlfaut JW, Soto JA, Lucey BC, Ulrich A, Rathlev NK, Burke PA et al. Blunt abdominal trauma: perfor-mance of CT without oral contrast material. Radiology. 2004; 233: 689-94.

10. Rutledge R, Lalor A, Oller D, Hansen A, Thomason M, Meredith W et al. The cost of not wearing seat belts. A comparison of outcome in 3,396 patients. Ann Surg. 1993; 217: 122-7.