Reoperation for bleeding in trauma.

OBJECTIVE

Analysis of the causes and clinical patterns of postoperative bleeding requiring reoperation in trauma patients.

DESIGN AND SETTING

A case series of 166 consecutive patients treated over 7 years at a level I trauma center.

PATIENTS

136 patients (82%) sustained penetrating trauma, primarily gunshot wounds (102 patients). On admission, 85 patients (51%) were hemodynamically unstable.

INTERVENTION

196 reoperative procedures were performed to control bleeding: 136 laparotomies, 49 thoracotomies, five neck explorations, and six peripheral vascular operations. Results of nine explorations were negative.

MAIN OUTCOME MEASURE

Of 157 initial attempts to affect hemostasis, 36 (23%) failed. Twenty-seven patients died of uncontrolled bleeding and 19 died despite successful hemostasis. The overall mortality rate was 28%.

RESULTS

Major causes of bleeding were incomplete hemostasis (46%), missed injuries (30%), and iatrogenic complications (17%). Diffuse oozing occurred in only seven of 43 patients with abnormal coagulation. The liver (19 patients) and retroperitoneum (13 patients) were the most common sites of incomplete hemostasis. Missed injuries occurred mainly in the chest wall arteries (seven patients) and heart (six patients). Iatrogenic injuries most commonly involved the spleen (nine patients).

CONCLUSIONS

The management of postoperative hemorrhage in trauma hinges on an early decision to reexplore, preoperative correction of abnormal coagulation, and knowledge of specific bleeding patterns.