Blunt trauma refers to physical trauma caused to a body part, either by impact, injury or physical assault. The abdomen is the third common region of the body injured in civilian trauma. Every year in India, about 1,40,000 individuals die in accidental deaths and approximately double the number are disabled. Every year the lives of approximately 1.25 million people are cut short as a result of a road traffic crash (Global status report on road safety 2018 WHO)1, 2

Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Injury to intra- abdominal structures can be classified into two primary mechanisms of injury-compression forces and deceleration forces. Compression forces may result from direct blows or external compression against a fixed object leading to tears and sub- capsular hematoma of solid viscera and may also deform hollow organs resulting in rupture. De-acceleration forces cause stretching and linear shearing between relatively fixed and free objects.3,4

ATLS provides a structured approach to the trauma patient with standard algorithms of care. It emphasizes the “Golden Hour” concept that timely prioritized interventions are necessary to prevent death5.In the recent years there is a paradigm shift from surgery to non-operative management of haemodynamically stable patients after abdominal solid organ injury is well validated. The key components of non-operative management include accurate assessment and staging of injuries with high quality CT. Clinical and imaging findings are now well established that indicate early use of interventional techniques such as angiography and embolisation.

AIM

To assess the Incidence of injury, mode of injury, clinical presentation, management and outcomes of solid organ injury in Blunt trauma abdomen

This prospective observational study consists of randomly selected 100 cases with blunt abdominal trauma admitted during the period of May 2019 to May 2020. After obtaining permission from institution research board the present study was conducted data was collected from under study population through a pretested and semi-structured schedule.Each patient was evaluated clinically taking into consideration history, general examination, abdominal examination, investigations.All patients were managed in trauma center as per ATLS guidelines and underwent appropriate primary resuscitation and investigations as per ATLS protocols for management of abdominal trauma and underwent exploration accordingly. The patients were followed up for a varying period of 15 days to 3 months.

INCLUSION CRITERIA

• All patients with blunt abdominal solid organ trauma.
• Patients presenting within 48 hrs of trauma.

EXCLUSION CRITERIA

• Penetrating abdominal injury
• All deaths on arrival
• Patients of blunt trauma abdomen without solid organ involvement.
• Pregnant females.

All data thus collected was entered in Microsoft excel and analysis was done by Epi info software from CDC.

In this study, most patients were between the age 20-45 years (70%), 15% patients were younger than 20 years of age, and the rest were older than 45 years of age. Males (89%) were found to be more prone to blunt abdominal trauma than females (11%) in this study of 100 patients.RTA remains the most common mode of injury in both males and females. RTA remains the most common mode of injury in both males and females.

The most common cause of blunt abdominal trauma in this study was found to be road traffic accidents (RTA).

The most common presenting symptoms in patients with blunt abdominal trauma in the present study was abdominal pain (99%) followed by vomiting and altered sensorium in 15% each. The most common presenting sign was abdominal tenderness (85%) followed by tachycardia (59%) and abdominal guarding in 40%.

In this study, 20 patients had moderate free fluid in abdomen on ultrasonography. Out of these 20, 18 patients underwent operative management and only 2 patients were managed conservatively.  Thus, moderative free fluid is an alarming sign in patients with blunt abdominal trauma.

Out of 100 patients in our study, CECT was done in 93 patients.  Most commonly diagnosed was splenic injury in 50 patients followed by liver injury in 42 patients. Out of 7 unstable patients for whom CECT was not performed, 5 had splenic injury and 2 had liver injury. In both splenic and liver injury most common are grade 2 injuries. Thus, most patients depending on the haemodynamic stability and associated injuries can be managed conservatively.

In 29 patients out of 100, blunt abdominal trauma was associated with chest injuries. The most common associated chest injury was rib fractures.

Out of 100 patients, 81 patients managed conservatively, and 19 patients underwent operative intervention. Out of 55 patients with splenic injury, 13 (23%) underwent exploration and rest 42 (77 %) were managed conservatively.

The patients that were managed conservatively had an average hospital stay of 5.3 days, as compared to patients who were operated (12.4 days) upon.

All patients who were managed conservatively were discharged from the hospital under satisfactory condition. All 3 of the deceased patients had higher than grade 4 injuries and were operated.

Table 1: Mode of injury

Table 2: Sign and Symptoms

Table 3: Grades of Injury in Different Organs Involved on CECT

Table 4: Organ Specific Management

This study 100 selected patients with blunt abdominal injury were analyzed at our hospital from May 2019 to May 2020.

In this prospective study, young males appear to be the most commonly affected population of society. Around 9:1 was the male to female ratio in this study. The male preponderance in our study reflects that the greater mobility of males for either work, such as drivers and mechanics for automobiles or recreational activities may be resulting in a higher exposure to the risk of traffic injuries.Similarly, J. Davis et al6fond 7:3 ratio in male female.

In our study, automobile accidents accounted for 78% of cases. This was equivocal with other studies conducted by Perry7 and Morton et al.8 Thus prevention of accidents can decrease fatality. Similarly, RTA is the most common mechanism of injury in studies by N. Mehta & colleagues9and Jayant et al10, as compared to fall and blows to abdomen.

Abdominal injuries are commonly associated with other injuries, and these may complicate the management and affect the outcome. In this study, 60 (60%) patients had other associated injuries.

The most common were the chest injuries that occurred in 29 (29 %) patients. In our reference studies chest injuries were the commonest association as 40% in N. Mehta & colleagues9 and 27% in J. Davis et al6.

Most of the patients (81 %) were presented to hospital within 4 hours after injury.

This was similar to another study in Uganda which found that two-thirds of patients in Kampala arrive in hospital within thirty minutes.11 In studies reviewed (from UK and Australia), trauma patients reach a competent trauma center in the shortest time possible, usually less than one hour.

In Qamari et al12 study, the sensitivity and specificity of FAST in detecting intra-abdominal free fluid was calculated to be 91.9% and 94.34 % respectively. In this study, FAST was the commonest tool used to diagnose patients with abdominal injuries. CT scan was done in pts who were having doubtful diagnosis, and in relatively stable patients after resuscitation. It identified the organ injuries effectively.

Spleen was the commonest organ injured (55%), followed by liver (42%), which is in comparison with our reference studies.

In both splenic and liver injury most common are grade 2 injuries.thus, most patients depending on the haemodynamic stability and associated injuries can be managed conservatively.

       Table 5: Comparative analysis

The most common presenting symptoms in patients with blunt abdominal trauma in the present study was abdominal pain (99%) followed by vomiting and altered sensorium in 15% each.

The most common presenting sign was abdominal tenderness (85%) followed by tachycardia (59%) and abdominal guarding in 40%which is similar to study ofJayant et al.10

In this study, there was more than one solid organ involvement in 7 cases.

81(81%) of patients were managed successfully with conservative management.Similarly, Jayant et al10found that 86.7% were treated conservatively and 84% in a study conducted by Reina et al15

• 19 (19%) patients in this study underwent a laparotomy. Spleen (55%) was the most common organ injured and splenectomy was the commonest treatment for higher grade splenic injuries. Out of 55 patients with splenic injury, 13 (23%) underwent exploration and rest 42 (77 %) were managed conservatively.
• Like other centres, conservative approach has been used and practiced in our centre also. Most of the injuries in both liver and spleen were grade 2 lesion on CECT and patients were hemodynamically stable so were managed conservatively.

This is in agreement with Wasimibrahimet al. in their study in Egypt hat reported more than 46% of patients treated operatively with most of them subjected to splenectomy. Currently non operative treatment is attempted in patients with splenic injuries.16

3 mortalities were noted in this study. All these 3 were operated and had grade 4 injuries

Road traffic accident was the most common mode of blunt trauma abdomen in the young and reproductive group males. Spleen is the most common solid organ injured; majority of patients were managed by conservative method.

1. Trauma, Sabiston's textbook of surgery, 20 edition, volume I. https://shop.elsevier.com/books/sabiston-textbook-of-surgery/townsend/978-0-323-29987-9
2. Cusheri A Giles G R MoosaA R. Essential surgical practice 1998. p 263-304 Gray's anatomy. 39" edition, 2005
3. Stassen NA, Bhullar I, Cheng JD et al. Eastern Association for the Surgery of Trauma. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S288-93. doi: 10.1097/TA.0b013e318270160d.
4. Gourgiotis S, Germanos S, Dimopoulos N, et al. Renal injury: 5-year experience and literature review. Urol Int. 2006;77(2):97-103. doi: 10.1159/000093899.
5. Cirillo RL. Koniaris LG. Detecting blunt pancreatic injuries. J GastrointestSurg. 2002:6:587-598. https://link.springer.com/article/10.1016/S1091-255X(01)00028-2
6. Davis et al. Diagnosis and Management of Blunt Abdominal Trauma, Annal of surgery, 1976 Jun, V. 183(6): 672-678. DOI: 10.1097/00000658-197606000-00009
7. Perry JFJr, McclellanRJ. Autopsy findings in 127 patients following fatal traffic accidents. Surg gynecol obstet. 1964 sep;119:586-90. https://europepmc.org/article/MED/14210161
8. Morton JH, Hinshaw JR, Morton JJ. Blunt trauma to the abdomen. Ann Surg. 1957 May;145(5):699-711. doi: 10.1097/00000658-195705000-00012.
9. Mehta N, Babu S, Venugopal K. An experience with blunt abdominal trauma: evaluation, management and outcome. Clin Pract. 2014 Jun 18;4(2):599. doi: 10.4081/cp.2014.599.
10. Jain J, Singh SP, Bhargava A et al. Study of management of blunt injuries to solid abdominal organs. Ijbamr 2016; 5 (2):219-224. https://www.ijbamr.com/assets/images/issues/pdf/March%202016%20219-224%20%20RR.pdf
11. Radwan MM, Abu-Zidan MI. Focused assessment sonographic for trauma (FAST) and CT scan in Blunt trauma. Surgeon's perspective. J Africa Health Science 2006, 6(3):187-190. https://www.researchgate.net/publication/6659293_Focussed_Assessment_Sonograph_Trauma_FAST_and_CT_scan_in_blunt_abdominal_trauma_Surgeon's_perspective
12. Qarnari N. Focused Sonography in Detecting Hemoperitoneum in Blunt Abdominal Trauma Patients, Correlation with Computed Tomography, International Journal of Medical Imaging. 2013:1(1). https://sciencepublishinggroup.com/article/10.11648/j.ijmi.20130101.12
13. Mohapatra S, Prahad S. Rao KRRM. Bastia B. Options in the management of solid visceral injuries from blunt abdominal trauma. Indian j surg 2003;65(3):263-268. https://tspace.library.utoronto.ca/handle/1807/21190
14. Khanna R, Khanna S. Singh P, Khanna P. Khanna AK. Spectrum of blunt abdominal trauma in Varanasi. Quarterly J Surg Sciences 1999;35(1): 25-28.
15. Khadilkar R, Yadav A S, D’silva A. A clinical study to evaluate and manage solid organ Injuries in blunt abdominal trauma. CIBTech Journal of Surgery 2015;4(1):5-9. https://www.cibtech.org/J-Surgery/PUBLICATIONS/2015/Vol-4-No-1/02-CJS-APRIL-2015-002-REINA-CLINICAL-TRAUMA.pdf
16. Skattum J, Naess P.A, Gaarder C. Non-OperativeManagement and Immune function After Splenic Inju BJS. 2012, 99(1):59-65. https://bjssjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.7764