From the Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles, California.
J Trauma Acute Care Surg. 2021 Jan 1;90(1):170-176. doi: 10.1097/TA.0000000000002970.
The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness.
National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures.
Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004).
The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage.
Therapeutic, Level IV.
对于严重头部和腹部联合创伤的低血压患者，需要根据开颅术或剖腹术的必要性、时机和顺序进行管理。本研究的目的是确定是否可以通过简单的临床参数在入院时确定需要开颅术的罕见情况。我们假设低血压很少与联合手术的需要相关，尤其是在意识轻度下降的患者中。
本研究纳入了国家创伤数据库研究中的成年钝性创伤患者，这些患者的头部（损伤严重程度评分≥3）和腹部（损伤严重程度评分≥3）均严重受损。数据收集包括人口统计学和临床特征、入院 24 小时内的剖腹术和开颅术、颅内病变类型、存活率和住院时间。多变量回归分析用于确定需要两种手术的预测因素。
在 25585 例严重头部和腹部联合创伤患者中，8744 例（34.2%）仅需剖腹术，534 例（2.1%）仅需开颅术，394 例（1.5%）在入院 24 小时内需要两种手术。在 4667 例低血压患者亚组中，2421 例（51.9%）仅行剖腹术，54 例（1.2%）仅行开颅术，79 例（1.7%）在入院 24 小时内同时行两种手术。在 711 例格拉斯哥昏迷评分（GCS）>8 的低血压患者中，仅 5 例（0.7%）需要开颅术。在入院时可获得的临床参数中，GCS 评分为 7 至 8 与低血压患者行剖腹术时行开颅术的需求最高独立相关（优势比，7.94；p=0.004）。
严重头部和腹部联合创伤患者需要开颅术的情况非常少见，在需要剖腹术的低血压患者中，GCS 评分为 7 至 8 是开颅术的独立预测因素。在 GCS 评分大于 8 的血流动力学不稳定患者中，首先进行剖腹术，然后在稍后阶段进行 CT 扫描以处理头部可能更为安全。
治疗性，IV 级。
