Abdominal Surgery and Trauma

### **Chapter 1**

## Blunt Abdominal Injury

*Pabithadevi B. Mehanathan, Subash Metha, Athisayamani Jeyapaul and Reesha Pa*

#### **Abstract**

Road traffic accidents are one of the leading causes of mortality. Blunt injury to the abdomen contributes to mortality second to head injury. The mechanism of injury in road traffic accidents is due to blunt force created by collision between the patient and the external forces and acceleration and deceleration forces acting on the person's internal forces. The common solid organs involved in blunt abdominal trauma are the spleen, liver, and kidney. Mesenteric tears and isolated small bowel injuries can also occur. A high degree of suspicion and watchfulness, regular examination, imaging, and investigations are needed to diagnose blunt abdominal injury. The eFAST exam is an emergency screening tool used to diagnose intra-abdominal injuries in emergency departments. Treatment for these injuries depends on hemodynamic status, whether stable or unstable. Hemodynamically unstable patients with a positive eFAST exam will be taken up for emergency exploration, while stable patients will undergo further imaging and investigation to plan management. This chapter discusses the grades of injuries in the spleen, liver, mesentery, and retroperitoneum. It also discusses the various diagnostic and treatment modalities available and when and where to use them. This chapter is useful for surgical postgraduates, aspiring surgeons, and trauma surgeons.

**Keywords:** blunt abdominal injury, AAST grading, splenic injury, liver injury, retroperitoneal hematoma

#### **1. Introduction**

Abdominal blunt injury is a common emergency in emergency departments that regularly results from road traffic accidents, assaults, or accidental falls. Since the occurrence of road traffic accidents is increasing, they are now the leading cause of global disease burdens. According to the 2013 Global Status Report on Road Safety, more than 1.3 lakh people died on Indian roads, giving India the dubious honour of topping the global risk of fatalities from road crashes. Head injury, fractures, and blunt abdominal injury are the common causes of death in road traffic accident injuries.

#### **2. Mechanism of blunt abdominal injury**

Intra-abdominal injuries secondary to blunt force are due to collisions between the injured person and external forces and the acceleration and deceleration forces acting on the person's internal organs.

#### **2.1 Deceleration**

Rapid deceleration causes differentiating movement among adjacent structures. As a result, shear forces are created and cause injury to hollow, solid visceral organs and vascular pedicles at relatively fixed points of attachment, for example, a hepatic tear along the ligamentum teres. As bowel loops travel from their mesenteric attachments, mesenteric tears with resultant splanchnic vessel injuries can result.

#### **2.2 Crushing**

Intra-abdominal contents can be crushed between the anterior abdominal and vertebral columns. Solid viscera such as the spleen, liver, and kidneys are more vulnerable to crush injuries.

#### **2.3 External compression**

External compressive forces such as direct blows or external compression against a fixed object result in a sudden and dramatic rise in intra-abdominal pressure, which can cause a rupture of the hollow viscus, in accordance with the principles of Boyle's law. The liver, spleen, small intestine, and large intestine are the most frequently injured organs in increasing order of frequency.

### **3. Clinical examination**

Abdominal blunt injury is associated with other injuries, such as head injuries or fractures, thus the presenting symptom will vary. For blunt injury alone, the patient will present with abdominal distension, abdominal pain, or hemodynamic instability.

Once the patient enters the emergency room, a primary survey is performed. Primary survey consists of:


Abdominal examination follows the primary survey and includes:


After primary examinations, clear the airway, resuscitate for breathing (if necessary), and insert a wide-bore IV needle for infusion or insert a central venous catheter. According to the Advanced Trauma Life Support (ATLS) definition, a patient is "unstable" with blood pressure < 90 mmHg and heart rate > 120 bpm,

#### *Blunt Abdominal Injury DOI: http://dx.doi.org/10.5772/intechopen.98568*

evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness, and/or shortness of breath.

If the patient is hemodynamically unstable, stabilize first with crystalloids, colloids, or blood transfusion (whichever is applicable) and perform an eFAST exam. If there is any evidence of free fluid, the patient is shifted directly to emergency operation theatre (EOT). If the patient is hemodynamically stable and the primary survey is negative, the patient can be shifted to CT scan and review. A strong suspicion is needed to diagnose blunt injury in the abdomen.

#### **4. Splenic injury**

Splenic injury is the most common visceral injury from violence. The likelihood of severe injury is increased in a diseased spleen.

Splenic injury is commonly associated with the left hemothorax, fracture of the left lower ribs, and injuries to the tail of the pancreas, left lobe of the liver, left kidney, or left colon. Direct compression of the spleen causes parenchymal injury. Rapid deceleration causes tears to splenic parenchyma. Direct blows to the abdomen (domestic violence or leisure and play activities) can also cause splenic rupture.

#### **4.1 Clinical presentation**


#### **4.2 Management of splenic injury**

Management of splenic injury depends on the hemodynamic stability of the patient and associated injuries. It can be managed nonoperatively, operatively, or via splenic artery angioembolization.

Patients who have diffuse peritonitis or who are hemodynamically unstable (a positive FAST examination or positive diagnostic peritoneal lavage (DPL)) following blunt abdominal trauma should be taken urgently for exploratory laparotomy. A routine laparotomy is not indicated in hemodynamically stable patients without peritonitis presenting with isolated splenic injury. Factors such as patient age, grade of injury, and presence of hypotension need to be considered in the clinical management of these patients. For patients undergoing nonoperative management (NOM), an abdominal CT scan with IV contrast should be performed to identify and assess the severity of injury to the spleen. Angiography should be considered for patients with AAST grade


**Table 1.**

*American Association for the Surgery of Trauma (AAST) splenic injury scale.*

III injuries. The presence of a contrast blush, moderate hemoperitoneum, or evidence of ongoing splenic bleeding is an indication for splenectomy. Nonoperative management of splenic injuries should only be considered in an environment that provides capabilities for continuous monitoring, such as serial clinical evaluations, serial HB estimation, serial radiological screening, and availability of an emergency operating room at any given time [1]. If vital signs or hematocrit values decrease, or if there is evidence of expanding hematoma or ongoing bleeding, the patient should be shifted for emergency laparotomy.

### **5. Liver injury**

The liver is the most common organ injured in blunt and penetrating injuries. Its anterior location in the abdomen and fragile parenchyma makes it susceptible to injury from blunt forces. Its fixed location under the diaphragm also makes it susceptible to shear forces from deceleration injuries. The vasculature in the liver is made up of large but thin-walled vessels with high blood flow (**Table 2**).

#### **5.1 Nonoperative management (NOM) of traumatic liver injury**

Blunt trauma patients with hemodynamic stability and absence of other internal injuries requiring surgery can be treated nonoperatively. Patients can undergo NOM irrespective of the grade of liver injury. NOM should not be used for patients with hemodynamic instability and peritonitis. NOM should be adopted in centers with facilities for intensive care monitoring, angiography, immediate availability of an operating room, and immediate access to blood products [2, 3]. CT angiogram should be performed in patients considered for NOM. If there is any blush in the CT angiogram, angioembolization should be considered. NOM patients should be continuously monitored for vitals, hematocrit, abdominal girth, and the development of peritonitis.

Complications of NOM include:



#### **Table 2.**

*American Association for the Surgery of Trauma (AAST) liver injury scale.*

#### *Trauma and Emergency Surgery*

If there is a decrease in blood pressure or hematocrit values or the development of any signs of peritonitis, the patient should be immediately taken up for laparotomy.

NOM can be used for penetrating liver trauma in hemodynamically stable patients without peritonitis, significant free air, localized thickened bowel wall, evisceration, and impalement [2, 3].

#### **5.2 Operative management (OM) of traumatic liver injury**

Patients should undergo operative management (OM) for liver trauma (blunt and penetrating) in case of hemodynamic instability and concomitant internal organ injury. The primary intention is to control hemorrhage and bile leakage. Major hepatic resections should be avoided in emergency situations and should be considered in subsequent management. Intraoperative management [2, 4] includes:


For patients undergoing hepatic packing, temporary abdominal closure can be performed to prevent abdominal compartment syndrome. Selective hepatic artery ligation can be considered for patients with massive hemorrhage. Associated portal vein injuries should be repaired because portal vein ligation can lead to hepatic necrosis and bowel edema. Hepatic resections can be performed for severe injuries with uncontrolled bleeding that is not controlled by any of the aforementioned means.

#### **6. Pancreatic injury**

Most pancreatic injuries are associated with spinal fracture at the level of the first and second lumbar vertebrae. Isolated injuries of the pancreas after blunt abdominal trauma were noted in 20% of pancreatic injuries. Pancreatic head injuries may be associated with injuries to the stomach, duodenum, and transverse colon. Injuries of the body and tail of the pancreas may be associated with injuries to the stomach, transverse colon, splenic flexure of the colon, splenic vessels, and spleen.

#### **6.1 Clinical presentation**

Direct blowing with compression of the upper abdomen against the spine is the most common cause of pancreatic injury. Many patients have minimal clinical symptoms and signs when evaluated after trauma. Pancreatic injuries will be *Blunt Abdominal Injury DOI: http://dx.doi.org/10.5772/intechopen.98568*

missed if not properly looked for because of minimal symptoms and signs. When symptoms present, the most common is deep epigastric pain associated with nausea and vomiting. Hyperamylasemia is not a precise marker for pancreatic injury. Hyperamylasemia is present in 30–40% of patients admitted with trauma, and the progressive rise in the amylase level over the first 24–48 h of hospitalization is strongly suggestive of pancreatic injury. CECT using 128 slice scanners is the diagnostic modality of choice. Endoscopic retrograde cholangiopancreatography (ERCP) can be used to rule out injury to the main pancreatic duct.

#### **6.2 CT findings**

In patients with suspicious pancreatic injuries, CT findings may include:


CT findings that are diagnostic of pancreatic injuries include:


#### **6.3 Management of isolated pancreatic injuries**

In hemodynamically stable patients, pancreatic contusions (AAST grade I), minor capsular injuries, and traumatic pancreatitis can be treated without drainage [6]. Most other injuries require some sort of drainage.


**Table 3.**

*American Association for the Surgery of Trauma (AAST) pancreas injury scale.*

AAST grade I injuries are managed with observation and omental pancreatorrhaphy with simple external drainage. Grade II injuries are managed with simple external drainage or omental pancreatorrhaphy and drainage. Grade III injuries are managed with distal pancreatectomy with or without splenectomy, and Roux-en-Y distal pancreatojejunostomy. Grade IV injuries are managed with pancreatoduodenectomy, Roux-en-Y distal pancreatojejunostomy, anterior Roux-en-Y pancreatojejunostomy, and endoscopically placed stent and simple drainage in damage control situations. Grades V and VI injuries are managed with pancreatoduodenectomy.

Complication rates after operative treatment of pancreatic injuries range from 26% to 86%. The most common postoperative infectious complication and the leading cause of morbidity in patients with pancreatic injuries is an intra-abdominal abscess. A pancreatic fistula is the most common pancreatic complication after operative repair of a major injury [5, 6].

#### **7. Renal injury**

The most common mechanisms that cause renal injury are motor vehicle collisions, falls, vehicle-associated pedestrian accidents, sports, and assault. Frontal impact caused by acceleration of the occupants into the seat belt or steering wheel, or side impact injuries, occur when the vehicle side panel intrudes into the compartment and hits the occupant, causing renal injury. Frontal and side airbags reduce the risk of renal injury by 45.3% and 52.8%, respectively. Sudden deceleration or a crush injury may result in contusion and laceration of the renal parenchyma. Penetrating renal injuries can occur as a result of gunshot or stab wounds. The incidence of urological tract injury following abdominal trauma is approximately 10%. Renal trauma comprises of 1–5% of all traumas.

#### **7.1 Clinical presentation**

Patients may present with localized pain, tenderness, or diffuse tenderness. Retroperitoneal bleeding may lead to abdominal distention, ileus, nausea, and vomiting. Features of hypovolemic shock may be present. Ecchymosis may be present over the flank on the affected side. Lower rib fractures or pelvic fractures may be frequently associated with renal injury. A palpable mass may represent a large retroperitoneal hematoma or perhaps urinary extravasation. If the retroperitoneum has been torn, free blood may be noted in the peritoneal cavity, but no palpable mass will be evident. Hematuria may be present [7].

#### **7.2 Investigations**

Contrast-enhanced CT is the gold standard for the evaluation of stable patients with renal trauma. The absence of enhancement on contrast administration or the presence of para hilar hematoma suggests renal pedicle injury and makes it difficult to directly visualize renal vein injury. Standard CECT scans may miss collecting system injury, which is best detected by repeating the scan 10–15 min after contrast injection. CT imaging is both sensitive and specific for demonstrating parenchymal lacerations and urinary extravasations, delineating segmental parenchymal infarcts, and determining the size and location of the surrounding retroperitoneal hematoma and/or associated intra-abdominal injury (spleen, liver, pancreas, and bowel). Renal artery occlusion and global renal infarct are noted on CT scans by lack of parenchymal enhancement or a persistent cortical rim sign.


#### **Table 4.**

*American Association for the Surgery of Trauma (AAST) renal injury scale.*

The most common indication for arteriography is nonvisualization of a kidney on intra venous pyelogram (IVP) after major blunt renal trauma when CT is not available. It is the test of choice for evaluating renal vein injury (**Table 4)** [8].

#### **7.3 Nonoperative management (NOM) of traumatic renal injury**

Stable patients with blunt renal trauma grades I–IV should be managed conservatively with bed rest, prophylactic antibiotics, and continuous monitoring of vital signs until hematuria resolves. Persistent bleeding represents the main indication for renal exploration and reconstruction.

#### **7.4 Operative management (OM) of traumatic renal injury**

Indications for operative renal exploration include:


The goal of renal exploration following renal trauma is the control of hemorrhage and renal salvage. Renorrhaphy or partial nephrectomy is used to manage parenchymal laceration. Attempts should be made for watertight closure of the collecting system. Raw areas should be minimized by using renal capsule, omentum, or fibrin glue. Repair of grade V renal injury is rarely successful, and nephrectomy is usually the best option, except in the case of a solitary kidney. The retroperitoneum should be drained following renal exploration.

#### **7.5 Complications**

Early complications occur within the first month of injury and can include bleeding, infection, perinephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation, and urinoma. Delayed complications include calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistula, hydronephrosis, and pseudoaneurysms. Peri-nephric abscesses are best managed by percutaneous

drainage. Delayed bleeding and arteriovenous fistula are managed by angiographic embolization. Treatment of hypertension is required if it persists and could include medical management, excision of the ischemic parenchymal segment and vascular reconstruction, or total nephrectomy. Urinary extravasation after renal reconstruction often subsides without intervention if ureteral obstruction and infection are not present. Persistent urinary extravasation responds to stent placement or percutaneous drainage.

#### **8. Mesenteric injury**

Isolated mesenteric injury is rare. Mesenteric tears occur because of deceleration injuries. The tear in the mesentery may be longitudinal or transverse. Longitudinal tears are more common than transverse tears. Longitudinal tears can occur from the base of the mesentery to the margin of the gut. The tear may be single or multiple. Longitudinal tears can be suture ligated without bowel resection if they do not extend up to the margin of the gut. Longitudinal tears can involve the root of mesentery and superior mesenteric vessels. Transverse tears are dangerous, as they will cause gangrene of the segment of the bowel. Clinically isolated mesenteric injuries present as follows:


#### **9. Traumatic retroperitoneal hematoma**

Retroperitoneal injury can be due to blunt or penetrating trauma. Blunt trauma is caused by direct energy transfer. A penetrating injury is an injury that directly violates tissue planes.

The retroperitoneum is divided into three zones.

**Zone 1** is the central retroperitoneum from the diaphragm superiorly to the bifurcation of the aorta inferiorly. It contains the inferior vena cava, origins of the major renal and visceral vessels, duodenum, and pancreas. Blunt trauma to this region affects the duodenum and the pancreas to a greater extent, with vascular lesions being less frequent. Pancreatic injuries have an incidence that ranges between 1% and 12% of penetrating trauma and 5% of blunt trauma. The most frequent complication is duodenal fistula.

**Zone 2** includes both lateral perinephric areas of the upper retroperitoneum from the renal vessels medially to the lateral reflection of the posterior parietal peritoneum of the abdomen (from the diaphragm superiorly to the level of aortic bifurcation inferiorly). Organs contained include adrenal glands, kidneys, renal vessels, ureter, and ascending and descending colon. Renal and adrenal injuries are common in this region.

**Zone 3** is inferior to the aortic bifurcation and includes the right and left internal and external iliac arteries and veins, distal ureter, and distal sigmoid colon and rectum. Mostly vascular injuries occur in this region. Iliac vessel injury occurs in this region [10].

#### **9.1 Management of traumatic mesenteric injury**

#### *9.1.1 Penetrating injury*

Zone 1—Major vessel injury can occur. Exploration must be done.

Zone 2—Selectively explore the kidney for active hemorrhage or an expanding hematoma. The colon is mobilized to rule out retroperitoneal colon injury and the ureters are explored if in proximity to the wound.

Zone 3—Explore as this is likely a major vascular injury.

#### *9.1.2 Blunt injury*

Zone 1—Explore, as this is likely a major vascular injury. The most frequent aortic injuries are infrarenal, while vena cava injuries are predominantly adrenal in origin. In the presence of hemodynamic stability and absence of contraindications, conservative management, including angioembolization, should initially be considered.

Zone 2—Conservative treatment is the most widely accepted. Exploration will be done for an expanding hematoma or one that has failed alternative methods of hemorrhage control, such as angioembolization, for the presence of associated injuries or when there is suspicion of ureteral injuries. Do not explore a contained, nonexpanding hematoma [10].

Zone 3—Do not explore and utilize a method for hemorrhage control, such as intraoperative preperitoneal packing or angioembolization. Iliac vessel injuries prevail in importance due to their associated high mortality. Angiography and venous ligation can be done. The management of bone injury is based on a multidisciplinary approach.

#### **10. Conclusion**

Blunt injury of the abdomen is a common abdominal emergency. A high degree of suspicion and watchful screening and examination are needed to diagnose blunt abdominal injury.

*Trauma and Emergency Surgery*

#### **Author details**

Pabithadevi B. Mehanathan\*, Subash Metha, Athisayamani Jeyapaul and Reesha Pa Department of Surgery, Tirunelveli Medical College, Tirunelveli, Tamilnadu, India

\*Address all correspondence to: pabitha73@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Blunt Abdominal Injury DOI: http://dx.doi.org/10.5772/intechopen.98568*

#### **References**

[1] Coccolini F, Fugazzola P, Morganti L, Ceresoli M, Magnone S, Montori G, et al. The World Society of Emergency Surgery (WSES) spleen trauma classification: A useful tool in the management of splenic trauma. World Journal of Emergency Surgery. 2019;**14**(1):1-25

[2] Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, et al. WSES classification and guidelines for liver trauma. World Journal of Emergency Surgery [Internet]. 2016;**11**(1):1-8. DOI: 10.1186/ s13017-016-0105-2

[3] Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: An eastern association for the surgery of trauma practice management guideline. Journal of Trauma and Acute Care. Surgery. 2012;**73**(5 Suppl. 4):20-21

[4] Ahmed N, Vernick JJ. Management of liver trauma in adults. Journal of Emergencies, Trauma, and Shock. 2011 Jan-Mar;**4**(1):114-119

[5] Debi U, Kaur R, Prasad KK, Sinha SK, Sinha A, Singh K. Pancreatic trauma: A concise review. World Journal of Gastroenterology. 2013;**19**(47):9003-9011

[6] Kobayashi L, Kluger Y, Ernest E, Ansaloni L, Biffl W, Leppaniemi A, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World Journal of Emergency Surgery. 2019;**15**:1-79

[7] Moore EE, Kluger Y, Biffl W, Leppaniemi A, Matsumura Y, Peitzman AB, et al. Kidney and urotrauma: WSES-AAST guidelines. World Journal of Emergency Surgery. 2019;**14**:1-119

[8] Moore EE, Cogbill TH, Malangoni M, Jurkovich GJ, Champion HR. Scaling system for organ specific injuries.

American Association for Surgery of Trauma – Grading for Spleen, Liver, Pancreas and Renal Injuries

[9] Wani I, Bhat RA, Wani S, Khan N, Wani RA, Parray FQ. Isolated small bowel mesentery injury after steering wheel trauma. Trauma Monthly. 2012;**17**(2):279-281

[10] Petrone P, Magadán Álvarez C, Joseph DA, Cartagena L, Ali F, Brathwaite CEM. Approach and management of traumatic retroperitoneal injuries. Cirugia Espanola. 2018;**96**(5):250-259

#### **Chapter 2**

## Rectus Sheath Hematoma

*Serhat Doğan, Selim Sözen, Burhan Hakan Kanat, Gökhan Söğütlü, Mehmet Gençtürk and Hasan Erdem*

#### **Abstract**

A hematoma is a collection of blood in an extravascular space and is named according to its location. Rectus sheath hematoma (RSH) was first described by Hippocrates and Galen about 25 centuries ago due to abdominal trauma, which is a rare cause of acute abdomen. It is uncommon, which may lead to delayed diagnosis in patients with acute abdomen. This condition arises due to trauma or hypertension in patients with bleeding disorders, using anticoagulants, doing heavy physical exercise, pregnant women, connective tissue diseases, and hematological diseases. The diagnosis can be made by detailed anamnesis, physical examination, ultrasonography, and contrast-enhanced abdominal tomography. For a accurate diagnosis, first of all, the medical history of these patients should be carefully questioned. CT and ultrasonography (USG) are used in the diagnosis of this condition. In many patients, conservative treatment by eliminating the predisposing factor is sufficient. In conclusion, with the increase in use of anticoagulation, the incidence of RSH is expected to increase. Every physician in the surgical field should keep rectus sheath hematoma at the top of the differential diagnosis list in patients presenting with acute abdominal pain and palpable abdominal mass.

**Keywords:** rectus, sheath, hematoma, trauma, therapy

#### **1. Introduction**

A hematoma is a collection of blood in an extravascular space and is named according to its location. Rectus sheath hematoma (RSH) was first described by Hippocrates and Galen about 25 centuries ago due to abdominal trauma. It was the first reported in the modern medical literature by Richardson in 1857 [1, 2].

RSH often has one or more of the risk factors, such as trauma, coagulopathy disorder, obesity, cough, or pregnancy. It may occur due to intense contraction of the rectus muscles during activities associated with the Valsalva maneuver. Patients are usually treated conservatively, but in some cases surgical intervention may be necessary. Cases causing abdominal compartment syndrome requiring surgical or endovascular intervention have been reported in the literature. Today, anticoagulation treatments are applied to more than 6 million patients in the United States for diseases such as atrial fibrillation, mechanical heart valve, or venous thromboembolism. This is a predisposing factor for RSH [3]. Most uncomplicated cases can be managed conservatively. The increasing incidence of RSH also increases the number of complications associated with them. Patients with coagulopathy typically have

one of the above-mentioned risk factors, but lack the natural ability to stop bleeding. This ability is also reduced in patients using anticoagulant drugs.

The rectus abdominis muscles originate from the fifth to seventh costal cartilages extend to the pubis, The rectus sheath surrounding the muscle consists of the aponeuroses of the lateral abdominal muscles. The epigastric arteries supply the rectus muscles. The superior epigastric artery is the terminal branch of the internal thoracic artery. The inferior epigastric artery is a branch of the external iliac artery. The inferior epigastric artery runs on the posterior surface of the rectus abdominis and enters the sheath at the arcuate line, passes upward, and anastomoses with the superior epigastric artery. The rectus muscles are separated in the midline by a band of connective tissue called the linea alba.

The rectus sheath is associated with the internal and external oblique muscles from anterior and the fascia of the transversus abdominis muscles from the posterior. Any infection or bleeding that develops in this area can progress through the cellular tissues and can go down to the pelvis. Patients can be taken to emergency operation mostly with the preliminary diagnosis of acute abdomen. Patients without acute abdomen are more stable.

#### **2. Definition**

RSH is a clinical condition caused by rupture of the rectus muscle or injury or spontaneous rupture of the epigastric vessels. It is a rare cause of acute abdomen. It is not very common, which may lead to delayed diagnosis in patients with acute abdomen. It can be seen due to trauma or hypertension in patients with bleeding disorders, using anticoagulants, doing heavy physical exercise, pregnant women, connective tissue diseases, and hematological diseases. It can also occur with a sudden sneezing, coughing, or sudden movement. In severe coughing cases, intrathoracic pressures may rise up to 300 mm Hg. With hemodynamic changes, systolic pressure rises up to 140 mmHg in the expiratory phase. These pressure and energy changes can also lead to undesirable results. Cough can cause complications in almost every system, from the cardiovascular system to the musculoskeletal system. RSH may also be one of these complications [4].

#### **3. Clinical presentation**

Rectus sheath hematoma has a sudden onset. It usually presents with a palpable mass under the umbilicus in the abdomen. It is more common in elderly patients and women with impaired rectus muscle structure. Pregnancy creates a trauma to the rectus muscle [5]. Ruptures of the superior epigastric artery usually result in small hematomas delimited by the rectus sheath. Hematomas caused by an inferior epigastric artery puncture are larger due to the absence of the posterior rectus sheath below the arcuate line and may grow beyond the midline and posteriorly [6].

Rectus sheath hematomas have abdominal pain in 84–97%, palpable abdominal wall mass in 63–92%, tenderness in 71%, defense in 49%, nausea in 23%, and vomiting and fever in 15%. Patients usually have sharp, severe, and persistent pain. The pain is constant where it does not spread. Pain generally increases with movement [7]. Large hematomas, although rare, can cause urinary tract obstruction and bladder irritability and even abdominal compartment syndrome. If it causes peritoneal irritation, gastrointestinal symptoms such as defense, rebound, tenderness,

#### *Rectus Sheath Hematoma DOI: http://dx.doi.org/10.5772/intechopen.101438*

anorexia, nausea, vomiting, or diarrhea may be present [8]. These findings may be accompanied by weakness, confusion, pallor, and sweating.

Abdominal bruising is a late sign. Bruising in the periumbilical region is a Cullen sign. Bruising in the flank areas is called Grey-Turner's sign. Both symptoms suggest an extraperitoneal extension of the intraperitoneal rupture. An interesting case of a patient with RSH is in the literature due to tetanus. The patient was hemodynamically unstable and was treated with percutaneous arterial embolization. The pathophysiology here is explained as damage to the epigastric arteries due to spasm of the rectus muscle [9].

#### **4. Physical examination**

Carnett's sign can help distinguish whether tenderness originates in the abdomen or the abdominal wall. If sensitivity increases or does not change when stretching the abdominal muscles, the test is positive and abdominal wall pathology is more likely. Conversely, in the case of intra-abdominal pathology, tenderness typically decreases when the abdominal muscles contract [10].

Fothergill's sign can help distinguish whether the mass originates in the abdominal wall or inside the abdomen. Fothergill stated that if the mass does not cross the midline and is palpated after contracting the rectus muscles, this is a rectus sheath hematoma [11].

It often occurs in the infraumbilical region and can easily be confused with intra-abdominal inflammation or mass lesions. It is more common in elderly and female patients.

Rectus hematoma has a characteristic appearance. You can easily diagnose it with inspection in the physical examination. For example, our patients photographs are shown in **Figures 1** and **2**.

#### **Figure 1.**

*Photograph of our 77-year-old male patient. One week ago COVID 19 +. He′s been hospitalized. He is receiving anticoagulant therapy for coronary artery disease.*

#### **Figure 2.**

*Photograph of our 86-year-old male patient. He was hospitalized two weeks ago due to COVID 19. At the end of the first week, he was taken to the intensive care unit. He did not use anticoagulants in his anamnesis. He has been receiving subcutaneous low-molecular weight heparin since hospitalization.*

#### **5. Diagnosis**

The average age of occurrence is 50–60 years [12]. The female male ratio is 2–3/1. It is more common in women [13].

The diagnosis can be made by detailed anamnesis, physical examination, ultrasonography, and contrast-enhanced abdominal tomography. For a correct diagnosis, first of all, the medical history of these patients should be carefully questioned. Drug use should be detailed. CT and ultrasonography (USG) are used in the diagnosis of rectus sheath hematoma. Although USG is used as the first option because it is fast, easy, and quick to reach and can provide information about the location of the mass, CT gives more meaningful results. It should be noted that the sensitivity of ultrasound is 80–90%. Ultrasound may give different results depending on the experience of the attending physician [14]. Tomography can diagnose with sensitivity and specificity reaching 100%. It also allows us to have information about the size, location, origin, spread, and nature of the hematoma. It helps to exclude other abdominal pathologies [15].

In most patients, the hematoma is self-limiting. Complete blood count and bleeding parameters are important in laboratory examinations. They are used for diagnosis and monitoring of treatment. The overall mortality rate in rectus hematoma is 4%. This rate rises to 25% in patients receiving anticoagulation therapy [16].

Treatment of rectus sheath hematoma is evaluated according to its type [17]. Rectus sheath hematomas that develop due to bleeding disorder and do not require intervention are usually limited to close follow-up, rest, and correction of bleeding disorder.

#### **6. Types and treatment approach**

It would be beneficial to start the treatment of RSH by first investigating the predisposing factors. After a good anamnesis, most of the predisposing factors are controlled. The drugs used should be carefully examined. Additional diseases of the patient should be evaluated in detail.

Predisposing factors in rectus sheath hematoma are as follows:


Preventing the predisposing factors mentioned above may be an option in treatment.

RSH is accompanied by many predisposing factors. More than one factor can be present at the same time.

The presence of comorbid diseases, especially in elderly patients, affects the treatment process.

It compels the physician to determine the treatment.

For example, if a patient with heart failure requires transfusion, neither incomplete nor excessive resuscitation should be performed. A balanced policy should be followed.

Or, for example, in a pregnant patient, the treatment protocol should consider the health of the mother and baby.

Rectus sheath hematomas are divided into three types according to their size and localization.

#### *Trauma and Emergency Surgery*

Type I hematoma is within the rectus muscle and only increases the size of the muscle. The hematoma is unilateral and does not spread to the fascia plane. Patients can be followed on an outpatient basis. It can be followed up with bed rest and pain relief. It makes up the majority of patients. It is a limited situation. Close follow-up is important. The course may suddenly worsen, especially in elderly patients.

Type II hematoma can be unilateral or bilateral. Intramuscular hematoma mimics type I, but there is bleeding between the muscle and the transverse fascia. It requires close follow-up due to the possibility of hematoma enlargement. Hospitalization should be given. In this type, rest and analgesics are used. Caution should be exercised in elderly patients. Predisposing factors should be determined and treatment should be planned for it. Frequently hemodynamic monitoring should be performed in the hospital. If necessary, transfusion should be applied. Patients can be discharged within a few days. Hematoma often regresses in 2–4 months (**Figure 3**).

Type III hematoma, bleeding occurs between the muscle and the transverse fascia, in the peritoneum and also to the prevesical area. Patients are hospitalized and treated under close follow-up. Fluid resuscitation and transfusion of blood and blood products may be required in necessary cases. Uncontrolled and progressive hematomas may require surgical intervention.

In such cases, a quick decision must be made. Treatment should be started immediately. Close hemodynamic monitoring is important. In case of teamwork, decisions must be made and implemented quickly. Time is precious and it works fast.

These patients can be discharged after 1 week of follow-up and the hematoma usually resolves in more than 3 months. Rectus sheath hematomas usually do not recur and do not leave sequelae in the long term. The morbidity and mortality rates are higher in receiving anticoagulant therapy, large hematomas, and elderly patients with serious comorbidities [18, 19]. Rapid treatment a bleeding disorder quickly and blood transfusion are the cornerstones of treatment in those receiving anticoagulant therapy.

In many patients, conservative treatment with the elimination of the predisposing factor is sufficient. Correction of coagulation disorders with vitamin K, fresh-frozen plasma, and protamine sulfate and blood replacement are recommended, especially in cases leading to severe anemia. Vascular embolization with catheter, evacuation of hematoma with drainage with USG, or vascular ligation with laparotomy are among the surgical options that can be applied. USG-guided hematoma drainage should always be considered as a minimally invasive option in these patients, as serious complications such as renal failure due to intra-abdominal compartment syndrome and small bowel ischemia may occur due to advanced hematomas (**Table 1**).

**Figure 3.** *Rectus sheath hematoma Type II (From Associate Professor Burhan Hakan Kanat's own private archive).*


**Table 1.**

*Types of rectus sheath hematomas and principles of clinical approach.*

#### **7. Rectus sheat hematoma treatment algorithm**

#### **8. Results**

In conclusion, with the increasing use of anticoagulation, the incidence of rectus sheath hematoma is expected to increase. Trauma, patients undergoing anticoagulation therapy, coagulopathy disorder, cough, trauma during surgery (iatrogenic),

#### *Trauma and Emergency Surgery*

vascular injury, severe gagging, severe vomiting, severe straining, obesity, and many kind of this predisposing factors cause RSH. An effective and fast way of treatment should be followed.

General practitioners, family physicians, emergency physicians, and every physician in the surgical field should keep rectus sheath hematoma at the top of the differential diagnosis list in patients presenting with acute abdominal pain and palpable abdominal mass, especially if there are predisposing factors. Fluid resuscitation or reversal of anticoagulation therapy is of paramount importance. The treatment plan should be decided according to the hemodynamic status of the patient and the characteristics of the hematoma. In the last year, the number of patients using anticoagulants due to COVID-19 has increased and the number of patients diagnosed with rectus sheath hematoma has increased.

### **Conflict of interest**

There is no conflict of interest.

### **Author details**

Serhat Doğan1 \*, Selim Sözen<sup>2</sup> , Burhan Hakan Kanat1 , Gökhan Söğütlü1 , Mehmet Gençtürk3 and Hasan Erdem3

1 Medical School, Department of General Surgery, Malatya Turgut Özal University, Malatya, Turkey

2 Sözen Surgery Clinic, Department of General Surgery, Vega Hospital, Tekirdağ, Turkey

3 İstanbul Obesity Surgery(IOC) Clinic, Department of General Surgery, Kurtköy Ersoy Hospital, İstanbul, Turkey

\*Address all correspondence to: drserhatdogan@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Manier JW. Rectus sheath hematoma. The American Journal of Gastroenterology. 1972;**57**:443-452

[2] Richardson SB. Rupture of the right rectus abdominis muscle from muscular efforts: Operation and recovery, with remarks. The American Journal of the Medical Sciences. 1857;**33**:41-45

[3] Drinnon K, Simpson SS, Puckett Y, Ronaghan CA, Richmond RE. Rectus sheath hematoma: A rare surgical emergency. Cureus. 2020;**12**(12):e12156. DOI: 10.7759/cureus.12156

[4] Poyraz B, Ülger F. Öksürük Komplikasyonları. Turkiye Klinikleri Journal of Pulmonary Medicine-Special Topics. 2014;**7**(2):10-12

[5] Zengin K, Carkman S, Kiliç I, Beken E, Eyüboğlu E. Treatment approaches to rectus sheath hematoma. Ulus Travma ve Acil Cerrahi Dergisi. 2007;**13**:55-59

[6] Teske JM. Hematoma of the rectus abdominis muscle: Report of a case and analysis of 100 cases from the literatüre. American Journal of Surgery. 1946;**71**: 689-695

[7] Titone C, Lipsius M, Krakauer JS. "Spontaneous" hematoma of the rectus abdominis muscle: Critical review of 50 cases with emphasis on early diagnosis and treatment surgery. Surgery, Original Communication. 1972;**72**(4):568-572

[8] Miyauchi T, Ishikawa M, Miki H. Rectus sheath hematoma in an elderly woman under anti-coagulant therapy. The Journal of Medical Investigation. 2001;**48**(3-4):216-220

[9] Inoue F, Ichiba T, Naitou H. Unusual adverse event of tetanus: Rectus sheath hematoma. Internal Medicine. 2021;**60**(1):151-153. DOI: 10.2169/ internalmedicine.4800-20

[10] Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surgery, Gynecology and Obstetrics. 1926;**42**:625-632

[11] Fotherhill WE. Hematoma in the abdominal wall simulating pelvic new growth. British Medical Journal. 1926;**1**: 941-942

[12] Sheth HS, Kumar R, DiNella J, Janov C, Kaldas H, Smith RE. Evaluation of risk factors for rectus sheath hematoma. Clinical and Applied Thrombosis/Hemostasis. 2016;**22**: 292-296

[13] Moreno Gallego A, Aguayo JL, Flores B, Soria T, Hernández Q, Ortiz S, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Journal of British Surgery. 1997;**84**: 1295-1297

[14] Fukuda T, Sakamoto I, Kohzaki S, Uetani M, Mori M, Fujimoto T, et al. Spontaneous rectus sheath hematomas: Clinical and radiological features. Abdominal Imaging. 1996;**21**(1):58-61

[15] Salemis NS, Gourgiotis S, Karalis G. Diagnostic evaluation and management of patients with rectus sheath hematoma. A retrospective study. International Journal of Surgery. 2010;**8**(4):290-293. DOI: 10.1016/j. ijsu.2010.02.011 (Epub 2010 Mar 19)

[16] Donaldson J, Knowles CH, Clark SK, Renfrew I, Lobo MD. Rectus sheath haematoma associated with low molecular weight heparin: A case series. The Annals of The Royal College of Surgeons of England. 2007;**89**:309-312

[17] Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: Diagnostic classification by CT. Abdominal Imaging. 1996;**21**:62-64

[18] Ducatman BS, Ludwig J, Hurt RD. Fatal rectus sheath hematoma. JAMA. 1983;**249**:924-925

[19] Dineen RA, Lewis NR, Altaf N. Small bowel infarction complicating rectus sheath haematoma in an anticoagulated patient. Medical Science Monitor. 2005;**11**(10):CS57-CS59

Section 2

Vascular Surgery and Trauma

### **Chapter 3**

## Blunt Traumatic Aortic Injury

*Domenico Calcaterra*

#### **Abstract**

Traumatic aortic injuries represent a leading cause of death following motor-vehicular accidents. These injuries curry a very high mortality rate even though a significant number of patients reaches the hospital alive. These injuries are identified in the contest of a polytrauma work up and are almost always associated with multiple other severe traumatic injuries which makes the management of these patients very challenging. The technology advancements seen in recent years with radiologic imaging and the progress of the therapeutic options brought up by the uprise of endovascular therapy, along with the sophistication of the techniques of trauma resuscitation and intensive care management, have improved significantly the overall prognosis of these patients. Although traumatic aortic injuries need to be generally considered a life-threatening condition, their degree of severity may differ significantly from case to case requiring immediate repair in some patients, whereas their repair can be delayed in cases when the severity of the aortic injury does not represent an immediate threat to the patient life. Therefore, the challenge of treatment of the polytrauma patients with an aortic injury is to identify the best strategy of therapy able to prioritize the treatment of the injuries based on their lethal potential. In this contest, the ability of properly defining the severity of the aortic injury is the key-factor to allow the appropriate definition of a treatment strategy able to identify treatment priorities. In our experience, radiologic assessment of the aortic injury in correlation with the evaluation of clinical parameters and a comprehensive polytrauma assessment allows to optimize the ability of the trauma team to establish the most appropriate strategy for the care of this complex patients' group.

**Keywords:** polytrauma assessment, traumatic aortic injury, thoracic endovascular aortic repair, radiologic assessment

#### **1. Introduction**

Traumatic aortic injuries (TAI) represent the second leading cause of death from motor vehicle crashes, accounting for 15% of all motor vehicle accident associated deaths [1–3]. According to a historical case series, death occurs at the scene of the accident in 70 to 90% of these cases [1, 3–7], and of the patients (75%) who arrive to the hospital alive, although hemodynamically stable, only 10% survives more than 6 hours [1, 3]. Patients with TAI surviving at the scene who arrive to the hospital alive most frequently present with an injury at the aortic isthmus, since periadventitial tissue in this location seems to provide some degree of protection against free rupture, allowing the necessary time to transfer the patient from the trauma scene to the hospital [8–10]. The majority of patients with BAI have an

#### **Figure 1.**

*Theories of blunt aortic injury. Blunt aortic injuries involve a combination of forces, including stretching, shearing, torsion, a "water-hammer" effect (which involves simultaneous occlusion of the aorta and a sudden elevation in blood pressure), and the "osseous pinch" effect from entrapment of the aorta between the anterior chest wall and the vertebral column (modified with permission) [11].*

associated closed head injury (51%), multiple rib fractures (46%), lung contusions (38%), or orthopedic injuries (20–35%) [1].

#### **2. Pathophysiology**

Blunt traumatic aortic injuries can involve any thoracic aortic segment, including occasionally even the abdominal aorta. The aortic isthmus is by far the most common location, followed by the ascending aorta (10–25%), the aortic arch (10–20%) and the abdominal aorta (5–10%). The theory is that a combination of sudden deceleration, associated to torsion, stretching and sharing forces, and thoracic compression, would cause the aortic injury (**Figure 1**) [11].

#### **3. Clinical management**

Diagnosis is made in the contest of the trauma work up as defined by the Advanced Trauma Life Support (ATLS) guidelines. Computed tomography (CT)

#### *Blunt Traumatic Aortic Injury DOI: http://dx.doi.org/10.5772/intechopen.98724*

scan is by far the test of choice to diagnose TAI with a sensitivity and negative predictive value close to 100%. In the very unusual circumstance that CT scan does not provide a definite answer and some doubt on the presence of a TAI remains, which would only occur in the case of a minimal injury, aortic angiogram, eventually with intravascular ultrasound (IVUS), represents the gold-standard to reach a definitive diagnosis. Once diagnosis is made, the severity of the injury assessed by imaging studies and the polytrauma assessment will dictate the treatment strategy [12].

Based on the application of ATLS protocols, treatment of the different trauma injuries will be prioritized based on their acute lethal potential [10]. Exsanguinating hemorrhages from any location and intracranial injury with mass effect take priority of treatment, unless hemodynamic instability obviously related to the imaging finding of an extremely unstable aortic injury would suggest to proceed with immediate endovascular aortic repair. In general, clinical management of the trauma patient arriving to the hospital requires the application of standard measures of trauma resuscitation aiming at establishing the best possible hemodynamic conditions. Once a TAI is diagnosed, anti-impulsive therapy with short-acting betablockers should be instituted, if allowed by hemodynamic conditions, to reduce aortic wall-stress. At that point the timing of the aortic repair should be decided based on the radiologic assessment of the aortic injury, the patient's general conditions, accounting in the decision-making process a polytrauma assessment which will allow to determine the sequence of therapeutic interventions offering the best chance of a positive clinical outcome [10].

In fact, although the vast majority of aortic injuries, based on a traditional 'old-school' approach, would represent an indication for therapeutic intervention, there has been more recently a strong school of thoughts proposing a conservative type of management for the type of injuries with a low lethal potential. In these cases, the therapeutic intervention can be delayed or completely aborted, selecting a strategy of radiologic monitoring which would allow to indicate a need for intervention only in cases showing evolution of the aortic injury in a growing pseudo-aneurysm [13–18].

The Society for Vascular Surgery (SVS) has proposed a grading system for TAI intended to rate the degree of severity of the injury (**Figure 2**) [19, 20]. Nevertheless, this grading system has failed to find reliable clinical correlation with risk of aortic rupture and death [15, 19–22], because this classification is qualitative but not quantitative, since can be useful to define the type of injury (intimal laceration versus intramural hematoma, versus pseudoaneurysm, versus free rupture), but does not include parameters to define size and extension of the injury. In our experience of blunt aortic injuries from 3 Level I Trauma Centers in the US from July 2008 to December 2016, we reviewed a total of 76 patients [12]. We analyzed overall mortality and TAI-related mortality (directly caused by the effects of the aortic injury) at 30 days in relation to factors such as: hemodynamic parameters on presentation (SBP, HR and need for vasopressor medications), timing of treatment, injury severity score (ISS) and aortic injury grade as defined by the Society for Vascular Surgery Clinical Practice Guidelines. Aortic injury (AI) grade was dichotomized as stable, grade I-II, and unstable, grade III-IV [12]. Using a new injury scale system, we classified the AI as "Severe" (Radiographic Severe Injury, RSI) when they included findings of [1] total/partial aortic transection (**Figure 3**), [2] active contrast extravasation (**Figure 4**), or [3] the association of 2 of more of the following: contained contrast extravasation >10 mm in bigger dimension, periaortic hematoma and/or mediastinal hematoma with >10 mm thickness, or left pleural effusion (**Figure 5**). We found that mortality caused by the aortic injury was associated with high ISS, SBP < 100, HR ≥ 100, and vasopressors requirement. Also, our

#### **Figure 2.**

*The Society for Vascular Surgery classification of traumatic aortic injury. Grade I: Intimal tear; grade II: Intramural hematoma; grade III: Pseudoaneurysm; grade IV: Rupture. This grading system has failed to find reliable clinical correlation with risk of aortic rupture and death and therefore cannot find use to indicate the lethal potential of the aortic injury and support the necessary choices that need to be made to select the most appropriate therapeutic strategy to improve the prognosis of the polytrauma patient with TAI (modified with permission) [19].*

new classification system of RSI, identifying patients with 'unstable' injuries, found statistically significant association with mortality (**Table 1**).

Therefore, our proposed system of grading of the aortic injury based on radiologic findings and the evaluation of clinical parameters, by the assessment of hemodynamic conditions (SBP, HR, and pressors requirement), is the most important elements to define the severity of the aortic injury and its lethal potential [12].

Besides the exceptional technical advancement of imaging studies that has allowed to increase tremendously the sensitivity to diagnose TAI, the most significant stride in the management of these injuries has been made by the rise of endovascular therapy, since treatment can be delivered with a faster approach using this much less invasive transcatheter technique and with substantial less operative and perioperative risk, compared to the 'open' surgical technique of aorta replacement used as the standard approach until a decade ago [15, 23–25].

Nonetheless, the choice of the most adequate timing for treatment of the aortic injury, particularly with respect to other major traumatic injuries, remains an area of active study. There are currently no clear guidelines for determining which patients may benefit from delayed aortic repair, nor there are validated methods of assessment of the severity of the aortic injury which would allow to choose when prioritize treatment of the aorta [15, 21]. A recent review of a small number of cases has suggested that some patients with small size pseudoaneurysms may be safely managed nonoperatively for the long-term [15, 25, 26]. Nevertheless, the ideal management for stable pseudoaneurysms after BAI remains a subject needing further study.

#### **Figure 3.**

*CT scan of the chest with IV contrast demonstrating aortic transection near the isthmus (red arrow), also associated with intraluminal aortic thrombus as shown by the blue arrow. (transection is defined by total or partial interruption of the column of intra-venous contrast flowing within the aortic lumen).*

In this contest, our system of classification created criteria for radiographic assessment of the degree of aortic injury used as a binary variable (severe versus non-severe), allowing to identify the patients in needs for immediate aortic repair.

The standard 'open' surgical technique of repair of TAI has been the replacement of the damaged aortic segment with a synthetic vascular graft. The most common

**Figure 4.**

*Sagittal and transverse CT scan images of large intravenous contrast extravasation as shown by red arrows (irregular IV contrast contour outside the aortic wall boundaries).*

location of the injury at the aortic isthmus requires a left thoracotomy approach, completing the aortic replacement with left atrial to femoral by-pass (**Figure 6**). This technique had replaced the previous approach of 'clamp and saw' (without use of partial cardiopulmonary bypass), which was associated with a very high incidence of complications, of which paraplegia secondary to spinal cord ischemia was the most common and devastating one. The strategy of replacement using left atrial to femoral bypass allows to maintain perfusion of the lower body after

#### **Figure 5.**

*Coronal and transverse CT scan images of periaortic hematoma (red arrows) and aortic pseudoaneurysm as shown by white arrows (pseudoaneurysm is defined by a regular intravenous contrast contour outside the aortic wall boundaries).*

cross-clamping of the aorta above the injured segment, providing a better degree of protection of the spinal cord and other end organs from ischemia (**Figure 6**).

Nonetheless, the operation is still associated with significant morbidity and difficult postoperative recovery, considering that has to be accomplished under the very dangerous conditions of an extreme emergency in patients most likely affected by multiple other traumatic injuries.

The real revolution in the treatment of TAI has been accomplished with the uprise of endovascular aortic repair, which has impacted remarkably on the overall prognosis of these patients allowing to obtain an expedite aortic repair, without the need of an open surgical approach, which translates in much lesser procedural stress, much lesser operative risk, especially in the contest of the common poor general condition of the polytrauma patient, and much easier postprocedural recovery.

The other significant progress in the treatment of TAI has been the realization that under certain conditions the repair of TAI ought to be deferred, prioritizing the treatment of other major concomitant traumatic injuries which represented a more immediate danger for the patient. In a relatively recent prospective multicenter study sponsored by the American Association for the Surgery of Trauma (AAST), the effect of early versus delayed repair was observed in 178 patients admitted with BAI between 2005 and 2007. The study concluded that 'delayed repair of 'stable' blunt thoracic aortic injuries is associated with improved survival [16].

The decision establishing the timing of treatment of TAI should be exclusively based on the characteristics of the injury as seen on CT scan imaging and on the assessment of clinical factors in relation to other associated injuries [15, 21–24]. The Injury Severity Score (ISS) has been used to predict risk of morbidity and mortality associated with blunt trauma since the 1970s. It was demonstrated initially to correlate well with length of stay, need for major surgery, significant disability, and death [27, 28]. ISS does have known limitations, such as more limited applicability to penetrating trauma or other trauma patients in which injuries are localized only to one body area [28]. However, it continues to be a valuable tool used prominently in trauma databases to assign an objective value to traumatic injuries and predict risk for significant morbidity/mortality.


*1 Univariate logistic regression.*

*2 Multivariate logistic regression.*

*Abbreviations: AI, aortic injury grade group: BAI, blunt aortic injury CI, 95% confidence interval; HR, heart rate; ISS, injury severity score; OR, odds ratio; RSI, radio graphic severe injury; SBP, systolic blood pressure; SVS, society for vascular surgery.*

#### **Table 1.**

*Logistic regression of factors predicting risk of overall mortality and BAI-related mortality [12].*

Thoracic endovascular aortic replacement (TEVAR) offers the advantages of a fast delivery of therapy, preventing a dangerous operation with partial cardiopulmonary bypass or hypothermic circulatory arrest, and less risk of postoperative paraplegia. Furthermore, endovascular therapy can be delivered in the operating room under portable fluoroscopy, offering the tremendous benefit of allowing simultaneous delivery of other therapies for associated life-threatening injuries, such as cranial decompression, transcatheter embolization or exploratory laparotomy, which would be significantly delayed by performing an open surgical aortic repair. The benefit of endovascular therapy is supported by the findings in the literature that have consistently shown substantial advantages of TEVAR over open repair in TAI [15, 29–36]. In our series, open repair was selected only when TEVAR was not feasible, such as in cases with no peripheral aortic access due to presence of intraluminal aortic thrombus, small size of femoral vessels, or presence of a total aortic transection which prevented delivery of endovascular therapy, as seen in the case of **Figure 3**.

As last consideration, in our experience we have observed a relatively small number of patients who died before any treatment was established. If historical series had reported that number to be significant, most recent reports have shown that of the patients surviving BAI at the scene, less than 5% would die of a direct aortic complication after arrival at the hospital [23]. The improvement of the techniques of resuscitation and trauma management, along with a consistent and early application of anti-impulsive therapy have positively impacted on the postadmission hospital mortality [23].

#### **Figure 6.**

*Technique of proximal descending thoracic aortic replacement with partial cardiopulmonary bypass: Oxygenated blood is drained from the left inferior pulmonary vein and pumped in the left common femoral artery, allowing perfusion of end organs distal to the aortic cross-clamping.*

#### **4. Conclusion**

The surge of TEVAR as the new standard for treatment for TAI has lowered the operative mortality for the treatment of this condition. However, the optimal timing for the delivery of therapy remains still unclear with respect to the identification of the patients who would require immediate intervention versus the ones for whom postponing treatment of the aortic injury would be preferable. The newly conceived radiologic classification system of TAI we use in our clinical experience is aimed at identifying the type of injuries associated with the highest mortality risk. Radiologic assessment of the severity of the aortic injuries with characterization of the presence of an 'unstable' and life-threatening condition should represent the primary factor to direct management strategy indicating the timing for the aortic repair and guiding treatment priorities.

#### **Author details**

Domenico Calcaterra Florida Atlantic University, Boca Raton, FL, USA

\*Address all correspondence to: domenicocalcaterra@hotmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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