The incidence of closed abdominal injuries in patients admitted to St. Luke's Hospital, Malta after being involved in road traffic accidents, though not alarmingly high, is certainly not negligible. Of course, in cases coming to post-mortem, abdominal injuries are found in a higher proportion, usually associated with other lethal injuries to head and chest. The diagnosis of blunt intra-abdominal injury is always difficult and often obscured by shock, unconsciousness and the presence of other injuries to the head, chest and limbs. The most important decision is whether to explore or not rather than to determine which particular organ has been damaged. If in doubt, it is better to look and see than to wait and see.peer-reviewe

Warrington, A.J.

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148 ABDOMINIAL INJURIES IN ROAD TRAFFIC ACClnENTS A. J. WARRINGTON Department of Su:rgery, University of Malta Incidence The incidence of closed abdominal in-juries in patients admitted to St. Luke's Hospital after being involved in road traffic accidents, though not alarmingly high, is certainly not negligibl'e. Of course, in cases coming to post-mortem, abdominal inju-ries are found in a higher proportion, usual-ly associated with other lethal injuries to head and chest. This comparatively low incidence is probably due to the fact that most traffic accidents take place at low speeds, partly because our roads do not encourage high speed driving (Camilferi, 1968). It is possible that with improve-ment in our roads the incidence of these injuries will rise' tho!ugh never to such pro-portions as in co'untries with Ilong stretches of first class roads and motorways. Abdominal in~,uries can be sustained by pec:lestrains knocked down by moving vehicles, drivers thrown forward! against the steering wheel, passengers knocking themselves agarinst the interior of vehicles and cyclists who hit their abdomens 8(:lainst the handle-bars. In contrast to head iniuries, which are comlmoner in those sitting in the front sea't, the position of passengers inside a car seems t'o have no bearing on the incidence of abdominal in-juries. Althou(:lh horse-drawn vehicles are still fairly common on our roads their drivers do not ,appear to sustain abdomi-nal iniuries to any great extent. A number of different mechanisms may be responsi-ble for productina these iniuries including compression, avulsioin, shearing tsresses, direct laceration by bony structures and Axcessive risA ill intra-llJlmioAI rorAssun'l in the case of hollow viscera. Fixed or(:lans Me more liable to injury than mobile: ones with the exception of the pancreas which is iniured in only 1-2% of cases. In tralu-ma to the unper abdornAO, the snleen is most often involved (Wilson, 1963), fol-lowed by the Hver and kidney. HoHow vis-cera are less commonly damaged. Injuries to the bile duct, gall bladder and ureters are rare' and damage' to the adrenals is even rarer. Diagnosis The diagnosis of blunt intral-abdominall injury is always difficult and often ob-scured by shock, lunconsciousness and the presence of other injuries to the head, chest and limbs. Not infrequently more than one abdominal viscus is involved. Pa-rieta[ dama(:le, haemoperitoneum, perito-nitis and retroperitoneal haemorrhage may occur separately or together. Intraperito-neal injury may not be apparent ~or hours or days, for example small intestinal per-foration, retrope'ritonea;l damage to the duodenum or cOllon, gangrene of small bowel following in}ury tOr the mesentery and del'ayed rupture of the spleen. The valliue of repeate'dl OIbserva,tions, preferably Iby the same experienced: observer, cannot be; too sltrongly emphasised. History of the accident from the patient if he is conscious or from reliable witness-es, if he is unconscious, is often helpful. One should try to assess the velocity of impact from the state of the vehicles, whether the partient was thrown Out and his position in the car at the time of the accident. No matter what other injuries exist one must always think of the possi-bHity of abdominal injuries especially in the unconscious patient. If a conscious patient complains of pain in the abdomen, loin or back the matter must be given serious consideration. Where possible, inquire about the site' and radlation of the pain, the passaqe of urine and whether it con-tained obvious blood. A desire to pass lUrine with inability to do so is very sug-oAstive of blarldAr anrI/or urethrRI Inll/rv. The presence of shoulder pain may signify diaphragmatic irritation from blood or in-testinal contents. On examination, the presence of pallor, cold c1ammry extremities and a rapid weak pulse are as important an indica,tion of in-ternal bleeding as a low blood pressure. Signs of continued bleeding when all vi-sible bleeding has been stopped and the blood volume restored point to the abdo-men as the source, provided thoracic in-juries and major pelvic .fractures have been excluded. The imprint of C'!othing on a yielding part of the abdominal wall means severe compression against the spin or back part of the pelvis, often with damage to mesentery or bowel watj\ (London, 1969). Local' tenderness and guarding may or may not indicate damage to underlying structures. A rectal examina,tion should be done in all cases as it may reveal rectal injury or a displaced prostate in complete rupture of the posterior urethra. In general, isolated abdominal physical signs can of-ten be misleading (Proctor, 1967) and a general consideration of the clinical pic-ture including the patient's response to resuscitation is often more helpful. Disten-sion, increasing or spreading tenderness and rigidity and! a rising pulse raite, how-ever, are all significant. There are three diagnostic ancillary methods which aid in the general if not in the specific diagnosis. These are: raidiology, diagnostic peritoneal: tap and, tOI a lesser extent, labomtory investiga'tions. Plain X-Rays of the abdomen may show fractures of the ,lower ribs Or pelvis or the presence of free gas in the erect or lateral films. In retroperitoneal rupture of the duodenum, retroperitoneal gas bubbles with an excep-tionally clear Psoas shadow may be found. Sim:i1arly, obliterated Teft renal and Psoas shadows, possibly with e'levated left dia-phragm, increased density in the left up-per quadrant and shifting of the gastric air bubble suggest injury to the sp:een. Of tile specialised radiolo~ical procedur~'s, using contrast media, I.V.P. is mandatory to ex-clude' serious renal injury, when suspect-ed, as well as to confirm the presence of a funcdoning contralaterall kidney. Gastro-grafin s1:udies and cysto-ure1:hrography are occasionally useful for demonstrating gas-149 trointestinal and bladder/urethral injuries. Arteriography of the liver, spleen and kid-neys remains of limited scope, particularly for technical reasons (Shepherd, 1971). Scanning with radioactive gold has been advocated to detect liver injuries (Wait, 1969). Four quadrant diagnostic peritoneal tap using a number 18 lumbar puncture needle or fine polythene tubing introduced through a thoracocentesis needle, can be of great assistance, if positive. The with-drawn fluid can be haemorrhagic, bile-stained or contaminated with faeces. A 'high amyllase content in this fluid is very suggestive of pancreatic injury. A negative peritoneal tap, however, is of no signifi-cance (Morton et al, 1957). Of the labo-ratory investigations, serial haematocrit readings are .of more value than a single haemoglobin ,estimation on admission. A very high serum amylase, when present, suggests damage to the pancreas, al-though it is not specific. Microscopic hae-maturia directs one's attentiOn to the uri-nary'tract. In practice;' the most important decision is whether to exp,!ore or not rather than to determine which particular organ ha~ been damaged. If in doubt, it is better to look and see than to wait and see. Management As in many cases abdominal injuries are found in association with other severe in-juries to the head and chest, it is essential to perform a rapid initial assessment of the patient's condition, establish and maintain a patent airwalY and ensure effective respi-ratory exchange as a, first step. The resto-ration ofa depleted blood volume is of little or no avail unless respiratory func-tion is quickly restored and adequately maintained (Gissane, 1967). Following this, severe bleeding must have high priority in treatment (Ward McQuaid, 1971). The requirements are rapid resusci-ta,tion using a wide bore intravenous can-nU[a andl adequate amounts of blood. Plas-ma or high molecular weight dextran may be used until blood becomes available. The insertion of a central venous pressure catheter isa useful guide to the adequacy of replacement and prevents overtransfu-150 sien. It must be remembered that the sm-gical centrel ef bleeding is eften an inte-gral part ef resuscitatien. At 'Iaparetemy, wide expesure, is essen-tid to' allew proper inspectien ef aH er-gans. Splenic rupture is easily and reward-ingly dealt with by splenectemy. In liver injuries the ebtiects are to' step the' bleed-ing, to' excise' devitalised tissue by seg-mental resectien er even lebectemy (Lit-tle and Williams, 1969), if necessary after extending the incisien intO' the chest, and to' provide drainage'. Routine decempres-sien ef the biliary system by 8' T-tube is' net universally accepted! (Faris, 1972). Hilar injuries and those at the junctien ef the hepatic veins and the inferier vena' cava remain a preblem. Kidney damage is usuaHv handled censervatively (,0 pit et aI., 1960) and nephrectemy at emergency laparetemy fer blunt injury sheuld be rare, unless the kidney is diseased. Simple ce-'Ienic perferatiens ma'y be sutured; more severely damaged! right colen may be dealt with by resectien andanastermesis (Reberts and Lavelle, 1966); badly injured left colen is preferably e'xterierised. Retre-periteneal haematemas near the bewel, especially duedenum and celen, must be explered (Ward McQuaid, 1971). Pancrea-tic injuries may re'Quire' simple drainage (Thempsen and McFarland, 1969), repair (Reberts and LaveHe, 1966), dista'l pan-createctemy er a Whipple type precedure depending en the extent and site ef the in-jury. Ruptured diaphragm sheuld be 'leO'k-ed fer and repairedl. If left, it can lead to strangulation later (Miller and Hewie, 1968) (Ward McQuaid, 1969). Bladder and er pesterier urethral injuries are net uncemmenly asseciated with severe frac-tures ef the pelvis. A'ltheugh it is 'Usual to' attempt catheterisatien when these in-juries are suspected', this, is by ne means the universa"'y accepted management (Miller, 1961). Mitchell (1948, 1963) cen-siders that catheterisatien eften cenverts an incemplete intO' a cemplete urethral rupture with the inevitable risk ef stricture later. He advecates suprapubic cystestemy in aB cases fellewed by endescepic as-sessment ef the damage after twO' to three weeks. One must remain alert to' the pesibility ef de:ayed and late cemplicatiens develop-ing days er weeks after the eriginal injury (Petty, 1973). These include delayed rup-ture ef the spleen (Kamal, 1967) and bewel, haemebilia and abscess a.fter liver in;mies and ':ate pseudecyst fermatien in the pancreas. Late ileus usually means pe-ritenitis, and may be due to' gangrene fre'1)' missed mesenteric injury. Conclus:on In cenclusien, abdeminal in~uries from read traffic accidents are likely to' beceme mere cemmen with increase in traffic den-sity and imprevement in the roads, en-ceuraging, if not permitting, faster speeds. I am cenvinced, 2nd statistics suppert my contentien, that a preperly fitted and wern seat belt can decrease considerably the incidence and seve.rity ef abdominal inju-ries to' car eccupants. When, hewever, these injuries eccur we should endeaveur to' diiagnese and treat them early and ener-getical,ly because as Gissane peinted out in 1962, the Bimingham experience leaves 'us "in ne doubt that any decrease in mer-tality and merbidity rates fellewing severe intra-abdeminal injuries is dependent more upon early and adequate resuscitatien and surgery than upen technical virtuosity at a later stage" (Gissane, 1962). References CAMILLERI, V.T. ('1968), S.L.H. Gazette, IV, 1, 20-27. FARIS, I. (1972), Brit. J. Surg., 59, 136. GISSANE, W. (1967), Ann. R. Coll. Surg. Engl., 41, 335. GISSANE, W. (1962), Ann. R. Coll. Surg. Engl., 30, 281. KAMAL EL·RIFI (1967), Brit. J. Surg., 54, 238. LITTLE. J.M. & WILLIAMS, C.W. (1969), Brit. J. Surg., 56, 603. LONDON, P.S. (1969), Proc. R. Soc. Med., 62, 248. MILLER, A. (1961), Proc. R. Soc. Med., 54, 563. MILLER, J.D. & HOWIE, P.W. (1968), Brit. J. Surg., 55, 423. MI'!1CHELL, J.P. (1948), Ann. R. Coll. Surg. Engl., 48, 13. MI,T'CHELL, J.P. (1963), Proc. R. Soc. Med., 56, 1046. MORTON, J.H. et aL (1957) Ann. of Surg., 145, 699. OPIT, L.J. et aL. (1960) Brit. J. of Surg. 48, 240. PEJTY, A.H. (1973), Ann. R. ColI. Surg. Engl., 53, 167. PROC: -:'OR, H. (1967), Proc. R. Soc. Med., 60, 950. SHEPHERD, J.A. (1971), Ann. R. Coll. Surg. Engl., 48, 11. 'I1HOMPSON, R.G. & McFARLAND, J.B. (1969), Brit. J. Surg., 56, 117. WARD McQUAID, J. (1969), Proc. R. Soc. Med., 62, 250. WARD MvQUAID, J.N. (1971), Ann. R. CoIl. Surg. 151 Engl., 48, 11. WAL:', A.J. (1969), Ann. R. ColI. Surg. Engl., 45, 319. WILSON, D.E. (1962), Brit. J. of Surg. 50, 381. D!EPRESSION IN GENERAL PRA!CTICE V. S. ZAMMIT General Practitioner Attempts to classify depressive illness have become increasingly more complex and controversia,l. Perhaps from the Gene-ral Practitioner's point 01 vic:w it is wise to adopt this simple but clear classification. 1. A naturallly motiva,tedi moodl or normal non-pathQlligicail reaction 2. Reactive or neurotic depression and 3. The depressive Psychosis. Experience in 'our fie,ld shows that onl,y aboult 5% of all depressions that we en-counter dai'iy belong to group (3). In my opinion any case belonging to this grorup should be immediately referred' to the psychiatrist or to a, mental hospital - pre-ferab,ly the former as adm:ssion as an in-patient is costly, regressive, diminishes the patient's self eSlteemandleaves him with a stigma which causes both embarassment and diffiwltieslater on in life. General Praotitioners should never treat such cases at home without the consultant's he1lpand under no circumstances shou'ld they pre-scribe any of the monoamino-oxidase in-hibitors. Irt: is rather a pity and also a tragedy that General Practitioners are not allways aware that their patients have been prescribed these preparations'. General Practitioners must be aware that they must not prescribe any of the tricvolic antide-pressive drugs, reserpine, pethidine, sym-pathomimeticamines, methyldopa, tyra-mine containing food such as cheese, yOCJhurt and' hrea,d beans and a~cohol in view of the serious and sometimes false effects. It is no exaggerartion to sta,te that at ,least 15% of 'a III adult cases that come to surgery are suffering from "depression" -the bulk being reactive which is an exag-gerated response to adverse exi1:ernal cir-cumstances - viz - family conf.lict in-cluding maritall discord, excessive use of alcohol, unemployment, financial worries, bereavement or grief reaction, problems of adolescence, and of old age, school pro-bf'ems, medical' Hlness, the unmarried mother, posltpatum depression and posto-perative reactions. A smal'l propol'tion of this percentage belongs to the endogenous type of depression which, as we all know, belongs to the realm of psychosis. Very of-ten 'as is the custom in Mallta, the patient is frequet:1t1ly brought in by a relai1:ive who gives the initial presenting features. Without being impolite I lusually ask the relative to leave the room a,s I believe that this is the first step to break down the barrier of the patient's initial reaction of "You cannot possibly he'lp me". Furthermore t:his helps in gaining the confidence of the pa,tient and to establish the most important and f.undamental criteria of family practice -the patient-doctorr~lationship. A word of warning regarding femal'e patients stress in front of the reliative that there wiH be no "initial" physical examination - this I feel puts the pa,tient's mind at rest and' diminishes some the worries that she may be harboring some serious physica,l i:llness. During the first session I usualily listen to the patient's complain~s hardly giv-

Abdominial injuries in road traffic accidents

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Abdominial injuries in road traffic accidents

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