Abdominal Trauma and Brain Injuryyyy

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Abdominal trauma and brain injury difficult condition, frequent association, specific consequences for emergency
medical prehospital team
Medrech
ISSN No. 2394-3971

Review Article
ABDOMINAL TRAUMA AND BRAIN INJURY DIFFICULT CONDITION,

FREQUENT ASSOCIATION, SPECIFIC CONSEQUENCES FOR EMERGENCY
MEDICAL PREHOSPITAL TEAM
*Luciana Rotaru1, Cristian Boeriu2
1
Associate Professor, Department of Emergency Medicine and First Aid University of Medicine
and Pharmacy Craiova, ED - SMURD County Clinical Hospital Craiova, Romania
2
Associate Professor, Department of Emergency Medicine and First Aid University of Medicine
and Pharmacy Tirgu Mures, ED - SMURD County Clinical Hospital Tirgu, Mures, Romania
Abstract
Background: Brain injury provides a significant percentage of, preventable deaths '' in trauma,
makes threaten in the highest degree the survival chance leads to definitive impairment of the
brain functions, generates traumatic disability and concomitant lesion associations.
Purpose of the paper is to highlight specific diagnosis but also management and evolution
medical issues that each of the two lesion types generates and which can lead to misdiagnosis
symptoms and signs.
We focused on the specific ways trough abdominal and brain injury interacts each other to
produce a traumatic complex evolving and adding secondary traumatic effects
In the same time we aimed to distinguish very particular emergency approach standards to
minimize the risks of worsening evolution
The method of study: We analyzed 398 patients assisted by the prehospital teams related to ED
County Hospital Craiova (2009 2012) with different association of multiple trauma lesions but
significant abdominal and brain trauma association
Conclusions:
1. Clinical examination data are difficult to analyze in the presence of altered mental status and
paraclinically resources must be widespread or systematic used.
2. Cervical spine lesions or spinal shock hide most significantly clinical abdominal signs.
3. Neurogenic shock can create confusion in the hemorrhagic shock interpretation.
4. Secondary brain injury is maintained or worsening by the presence of shock, but
overcorrection of those to.
5. General anesthesia should be early considered in tactics, techniques and means custom, which
has undeniable benefits in combating shock and brain protection
6. Temperature control should be considered
Keywords: multiple trauma, abdominal trauma, head trauma, traumatic brain injury,
hemorrhagic shock, neurogenic shock, golden hour
Rotaru L. & Boeriu C., Med. Res. Chron., 2015, 3 (1), 40-51
Medico Research Chronicles, 2016
Submitted on: January 2016

Accepted on: January 2016
For Correspondence
Email ID:
40
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Road accidents - 303 cases, of which

178 patients were passengers in vehicles,
81 were pedestrians hit by vehicles, 19
were motorcyclists injured and 25 were
cyclists.
Work / home/ sport accidents - 39
patients, (12 pitfalls, 6 car or motor
crush, 2 assault, 9 electrocutions.
Suicide attempts - 14 cases, among
which the most common mechanism the
precipitating (12 cases), stabbing (2)
Aggressions - 29 - 9 by blunt body
attacks, 11 stab wounds, 4 caused by
firearm, animal aggression - 5
Various other situations - 19 blast (11
victims), structures collapsing (6
victims), accidental falls or stinging into
sharp objects (2 victims)
On the studied group, out of the
bilesional associations with trauma score
(TS) less than or equal to 4, head injuries
are 6 out of 9, in the trilesional association
group, the head trauma appears in 28 out of
the 30 cases and in all cases with cvadri
regional association and trauma score below.
This leads to a strong argument for the need
of advanced management before the
worsening indicators becomes clinical
obvious, proactive brain injury approach
even since the accident scene and
alternative, reliable solutions for the precise
abdominal damage confirmation under these
conditions.
We calculated the trauma score (TS)
of each patient on admission to the ER and
we grouped the trauma patients according to
scores (Figure 1).
TS 3
25
21
20
15
10
5
0
TS 4
Ts 5
TS 6
TS 16
TS 7
TS 8
TS 3
TS 9
TS 10
Figure 1 Initial trauma scores groups sorted by lesion profile

Introduction
Head and spine trauma is a highly
expanded chapter in traumatology, on the
one hand due to frequency and association
with other types of trauma, the
consequences of mortality, morbidity and
posttraumatic sequelae, enormous financial
and material cost and complexity
management
to
controlthe
many
physiopathological disorders generated by it.
At the same time, abdominal injuries
frequently occur as lesional associations in
polytraumas, and abdominal pelvine
combination
creates
difficulties
of
interpretation, evaluation and managemnt of
these patients.
Materials and Methods
We annalyzed over 4 years, between
2009 - 2012 398 polytraumatized with head
trauma and abdominal trauma assisted in
ED Craiova, brought in, from outside the
hospital by first aid and medical prehospital
emergency teams of different levels of
competency or by the relatives. A significant
part of the assisted polytrauma presented an
association of the
abdominal trauma
component (including of thoracoabdominal
or abdominopelvine border) with brain
injury. We have grouped these patients by
the lesional mechanisms that generated the
context of traumatic lesion, then analyzed
the frequency ofa bdominal trauma and head
trauma & cervical spine lesions association.
Occurrence
circumstances
and
mechanisms of trauma resulting from the
types of accidents of which they victims
resulted from were:
41

We divided the patients according to

the level of competence of the crew that
took the patient from the accident side[1]
(first aid, medical with GP / medical with
nurse, resuscitation team or ground/HEMS
ICU prehospital medical team), or as the
case of bystanders intervention - with
management complexity initially established
and possible difficulties, problems or
complications occurred. We followed later
in the dynamic evolution of trauma scores
throughout the golden hour "in each of these
classes of patients (graphs 1-4)
Primary and secondary survey to
these patients represented every time a
challenge, establishing investigative strategy
and management priorities, to find the
optimum compromise for meeting specific
management objectives for each of these
lesion combinations and time setting for
their final decision, as well as surgical

gestures hierarchy within some emergency
and trauma team accomplish their
competency.
I thought it appropriate to consider
all these difficulties in interpretation and
management encountered not only the ED
assistance but also during the subsequent
management strathegies of these patients, of
the
possible causes of confusion or
omission of injuries and of the factors can
avoid the production of such issues.
Results & Discussions
The following are detailed categories
of patients enrolled in different classes of
scores oft trauma and posttraumatic lesion
associations and the developments of trauma
scores for each working group and the
original score during the golden hour
trauma.
TS EV OLUTION ( initia l TS 4-6)
br ought by nonmedical
means
Graph 1 - trauma score dinamic to TS

group 4-6
assisted by ordinary
ambulances
8
6
assisted by prehospital
resuscitation teams
4
2
0
0 10 20 3 0 40 50 60
TS EVOLUTION (INITIAL TS 7-1 0)

brought by nonmedical
means
ambulances
12
10
Graph 2 - Evolution of the trauma score in

patients group with initial TS 7-10
resuscitation teams
6
4
2
initially ordinary
ambulances, and
transferred to
resuscitation prehospital
teams
0
0
10
20
30
40
50
60
initially ordinar y
ambulances, and
tr ansferred to
teams
42

TS EVO LUTION (INITIAL TS 11-1 4)
Graph 3 - Evolution of the trauma score

for patients with initial TS 11-14
means
ambulances
16
14
12
resuscitation teams
10
8
6
4
2
initially ordinary
ambulances, and
transferred to
teams
0
0
10
20
30
40
50
60
TS EVOLUTION (INITIAL TS 15-16)

means
ambulances
Graph 4 - Evolution of the trauma score in

patients with initial Ts 15-16
16
15. 5
resuscitation teams
15
14. 5
14
Studying the collected data in these

graphs some outstanding issues are revealed:
as small was the initial trauma score, as
faster dynamic deterioration[2,3] was to the
patients group brought by lay rescuers: more
than that, the worsened condition still
remain out of possibility of compensation by
the emergency medical teams after
admission to ER (on average, the last 20
minutes of the ,,golden hour"), so trauma
score continued to remain low, or decrease
throughout, the ,,golden hour"
to the patients assisted by mobile advanced
teams in trauma resuscitation, trauma scores
increased more abrupt and early to the
patients that the medical team took[2-5] over
the operation from the beginning than with
patients who were extracted from the place
13
0
10
20
30
40
50
60
of the accident by the bystanders, even if

they were assisted after that by a specialized
team. We always must keep in mind that
after induction of general anesthesia, trauma
score decrease due to the neurological
component (GLASGOW COMA SCORE
reduced according to the type and depth of
general anesthesia protocol). Even so, there
is a substantial improvement in scores of
trauma patients assisted by pre-hospital
resuscitation team vs. others patient category
s[6] (brought by unspecialized ambulance, to
which the changes in the trauma score are
induced directly from natural real evolution
its.
the category of trauma patients with initial
trauma score 11 - 14 is a particularly
interesting category to be considered
initially ordinary
ambulances, and
transferred to resuscitation
prehospital teams
13. 5
43
carefully because on one hand, the initial

score does not always indicate at first glance
a major imminent risk, but on the conditions
of only bystanders / ordinary ambulances
assistance, the rapid deterioration in trauma
score level in the first 20 - 30 minutes may
place these patients at high risk patient
group. This is the category of "avoidable
deaths in trauma, or of the patients that,
talk and die"[7] since quality intervention
may actually be saving without being
particularly complicated but extremely
proactive and more safety measures. In this
category fall the mild head injuries, GCS 913[2-4]. The patients presents late
quantitative or qualitative alterations of
consciousness lasting for hours after impact
associated with autonomic reactional
phenomenon, focal neurologic signs,
suggesting for increased intracranial tension.
Significant
mortality
and
residual
disability[7-9], significant rate of positive
CT/MRI[10] and required neurosurgical
interventions consistent especially when
previously special condition such as the risk
for intracranial bleeding, therefore, these
patients required army expectative, early
management of vital functions - especially
of the airway despite controversies[11] and
ventilation before clinical impairment,
adequate sedation, neurosurgical advisory
for transfer / admission /observation.
From this perspective, the long term
benefits brought by this approach, based on
the physiological peculiarities of this special
joint lesion, are much higher in real terms
than those reflected by differences in the
absolute values of scores compared to
previous trauma.
The two categories of factors
incriminated into the pathophysiological
changes in brain trauma consists in primary
brain injury generated by trauma, defined as
diffuse or focal primary brain lesions and
the secondary brain injury mainly resulting
from hypoxia, hypercapnia, hypovolemia. It
accepts also be incriminated: hypo /

hyperglycemia, hyperthermia, seizures and
not least hyperoxia / iatrogenic hypocapnia.
Secondary brain injury determinism
is therefore multifactorial, evolutionary,
worse by the inadequate / submaximal / late
management, conditioning the complexity
and sequence of management, generating
dynamic consequential effects and, finally,
affecting the neurological outcome [3-6]. In
this direction, the turntable in generating
secondary brain injury is represented by the
cerebral perfusion flow related to the
intracranial pressure. Increased intracranial
pressure leads to decreased cerebral
perfusion pressure, unless the median
arterial systemic pressure increases, an
effect limited by the development of
cerebral edema. This means that any
procedures to reduce intracranial pressure
tend to increase cerebral perfusion, and
factors that lead to low blood pressure
(hypovolemia in this case) tend to
compromise cerebral flow. In the same time,
any condition leading to increased metabolic
brain rate tend to compromise the balance
between brain metabolic supply vs. dept,
extending and aggravating secondary brain
injury, often with more important
repercussions on the outcome than the
primary one.
In case of severe myelic lesions,
affecting sympathetic system, neurogenic
shock, resulting in installation of
maldistribution and manifested by lowering
BP, bradycardia and absence of signs of
hemodynamic compensation, may be not
only an additional element of brain suffering
but also a risk of masking other sources of
hypovolemic shock like hemorrhagic is[12,13].
In the same way, the evolution of primary
and secondary brain injury, of the side
effects of head trauma, the effects of
removal, modification of pain threshold and
alteration of sensitivity, all of them can all
hide behind an impressive injury or very
44
painful one, as a broken column with

dramatic consequences (the myth of ,,occult
cervical fracture'') as well as an originally
myelic section screen may actually show as
a spinal shock with a real chance of
remission if adequate approach established
Special issues that may augment the
severity and prognosis strike, when myelic
lesion really exists, proved to be hiding
signs of peritonitis related to altered
perception of pain, loss of muscle tone,
confusion
between
neurogenic
and
hemorrhagic shock - misleading behavior,
minimizing neurological symptoms of
primary brain injury in head trauma with
cerebral transient component or other factors
that alter consciousness, meaning secondary
brain injury. It is also possible that the
presence of several injuries in the same
anatomical region may cause overlooking
the cervical lesions [12, 13].
It is rarely observed that as the early
stages of shock (adrenergic reaction) are
masked in the presence of severe brain
injury with the development of Cushing's
triad, bradycardia and hypertension may
divert attention from abdominal trauma.
Likewise, the myelic section at the cervical
level or installation of a spinal shock in a
myelic contusion by affecting the cervical
sympathetic, not only mask tachycardia, but
trough generating vasodilatation, cancels
any
compensation
possibility
of
hemorrhage, while perception of pain and
signs of peritoneal irritation also abolished,
make impossible the patients signaling
(even consciously) of any alert sign of a
possible intra-abdominal injury [14].
This is why FAST examination
performed systematically in the resuscitation
area, or even in prehospital if available, in
any patient with brain trauma is mandatory
with particular advantages in certain
circumstances over CT [15], although not
sufficient, since the retroperitoneum offers
little space access for this investigation and
the previous presence of poured ascites

cancel the benefits, forcing the practice of a
CT with iv. Contrast or angiography (with
therapeutic benefits in case of treatable
lesions discovered).
All these are strong reasons to
approach the obvious head and spinal
trauma patient with all the resources for a
major injury not only limited to these
segments, especially with high probability of
existence of abdominal visceral injuries
(nature visceral pain- softer, more diffuse
and difficult to appreciate by a patient with
multiple sources of somatic pain) until
proven otherwise.
On the other hand, if patients with
intraperitoneal
lesions
have
proven
relatively easy to layer, in the case of
retroperitoneal lesions, the suspicion has
been clinically the most valuable
component. Both renal lesions and those of
the ureter and not least the bladder requiring
serial FAST examinations and CT with
repetead IV. Contrast confirmed in 3 cases
to specify the location and type of lesion,
and in four cases a cystoscopy was
immediate necessary. Important genital
lesions such as massive metrorrhagia due to
cervical body dezinsertion of the uterus from
the vagina (abdominopelvine trauma by
pelvis crushing) and retroplacentary
hematoma in 2 situations of abdominal
trauma in third trimester pregnant women
have raised important problems to highlight
the
lesion,
including
radiological
investigation in pregnancy and of
therapeutic solution. Not last, the contusion
of the sigmoid and respectively its
penetrated wound through the bone dodge
from the iliac wing complex fracture in a
shooting case - the requiring immediate
rectoscopy followed by left iliac external
anus.
By far the retroperitoneal hematoma
was the most challenging diagnostic and
therapeutic the poverty of the clinical signs
45
even in patients aware and cooperative, the

difficulty of examination, the poverty of the
investigation means (basically just CT [15] iv
contrast agent with benefits, and in 4 cases
selective arteriography), difficulties in
assessing the blood loss, especially
therapeutic intervention opportunities and
difficulties in tactical decisions making [5].
Complex pelvic injuries were the causes of
these situations in 83% of cases and isolated
abdominal trauma in only 11%, all the rest
being generated by lumbar trauma. This
obviously raises the issue of intra-abdominal
injuries caused by sub sequential impact on
adjacent areas, which frequently leads to
underestimation of intra-abdominal injuries,
especially retroperitoneal.
Multiple sources of different types of
shock coexistence were another serious
problem. In 46.35% of cases the patients had
more than 2 sources of hemorrhagic shock
(external bleeding and haemoperitoneum),
18.11% had three or more sources of
hemorrhagic shock (haemoperitoneum,
external bleeding, retroperitoneal hematoma,
complex fractures the cob or basin) and to
31% the mechanisms of the shock were
different
(both
hemorrhagic
and
neurogenic).All that leads to conclude that
the right initial decision have to be to start
initial fluid resuscitation for hemorrhagic
shock [16, 17].
As another matter of fact, it is to be
discussed the impact of certain therapeutic
decisions absolutely necessary in abdominal
trauma in neurological traumatic impairment
context and equally the impact of some
standard treatment strategies on monitoring,
diagnosis and management of abdominal
injuries. Thus a number of tactical measures
should be harmonized, implemented and
prioritize as follows:
Quick vascular refill vs. antiedematous
therapy - the balance point is represented
by the identification as early as possible
and removing all sources of bleeding.
Deciding early if the blood transfusion is

the most profitable method of vascular
refilling up [15-17] to the admission in the
operating room and satisfying the desire
to supplementary oxygen transporter and
thus improve the hematosis, and also the
clotting factors if associated with fresh
plasma [18]. Worsening condition is thus
avoided in term of controlling ICP,
limiting ischemic secondary anemic
brain injury or coagulation factors
dilution.
Antiedematous agents should be used
with caution in hemorrhagic or
hypotensive patient, so elevated ICP
control is more profitable to be achieved
by
general
anesthesia,
adapted
hyperventilation
and
temperature
control, except, of course, the
neurosurgery intervention.
Anesthesia and sedation procedures in
particular, are both means of controlling
intracranial pressure optimization of
cerebral metabolism, brain and systemic
oxygen consumption by increasing the
seizure threshold and thus limiting brain
injury and overall the pain control,
which is the most important factor for
the initiation and maintenance of shock.
It is essential that the trauma team
understand that the pain is in no way an
important clinical indicator for diagnosis
or management orientation and thus its
cropping does not bring any harm to this
directory and but has positive
consequences invaluable in optimizing
the
patients
condition,
pain
management with all means available,
tailored obviously to the patients profile
becomes an absolute standard of
management.
General anesthesia, facilitating the
establishment of controlled ventilation
leads to optimize oxygenation beneficial
in all hemorrhagic shock. The impact of
general anesthesia established in relation
46
to its generic indications or not

established in circumstances that would
have required it, is clear from the
evolution of the scores of trauma
patients. Real benefits of general
anesthesia, resulting in increased
survival of about 8, 5% - expressed on
three categories of patients:
Severe brain injury category of patients the main element of the combination, crush
induction supported on barbiturate pivot
followed by mechanical ventilation - IPPV
(17, 19) with ICP control increased survival
by 5.2% compared to patients who received
only
sedation
variants
without
neuromuscular block and associated with
assisted ventilation only. The issue of EEPP
(end expiratory positive pressure) is equally
important to decide, because of the impact
both on the ICP and venous return, and
trough that on the cardiac output and
hemodynamic balancing. In the same
direction the association of pulmonary
contusion and cardiac contusion must be
disclosed because of the relationship with
the ventilation and anesthetic protocol [19, 20].
patients with a ruptured diaphragm or
chest wall as specific elements of
seriousness to which the achievement of
general anesthesia focused on one hand on
facilitating the mechanical ventilation with
negative intrathoracic time pressure
cancellation and mediastinal balance and
thus improving venous return and
oxygenation
Patients with hemorrhagic shock - general
anesthesia are improving oxygenation and
decreasing agitation, muscle effort and
rebalancing vital regional blood flows and
oxygenation, additionally sustained by using
suitable anesthetic drugs.
Some preconditions are necessary to
these benefits occurrence such as:
advanced airway control, ventilation and
circulation to satisfy all advanced
tactical principles
use of appropriate drug combinations

pathophysiological according to the
profile of the patient
The most profitable scheme induction in
patients with brain injury and
hypovolemia proved to be deep sedation
[21]
(combining
etomidate
benzodiazepine fentanyl), almost in the
same sequence as being used to classical
rapid sequence induction [22, 23, 24]. There
is practically no difference in survival
that can be attributed to the two types of
induction, but the high quality of
sedation and of ventilation remains
mandatory for the prognosis. Compared
with, using only some sequences of
sedation either without assisting the
airway, ventilation and circulation, or
with weak medical standardization
generated up to 35% lower survival rate
than the same group of TS (9-11)
patients for whom it was proceeded to
correctly anesthetic induction for the
same profile lesion. In lower TS groups
the survival chance gap reaches up to
62%
assisted/
controlled
ventilation
strategy[25] of the patient, impact
volume ventilation regime, the pressure
(including PEEP) or BiPAP, are
recognized aspects with high impact on
both the ventilation optimization and
oxygenation but also with effects on
ICP, intrathoracic pressure and through
it of the venous return, thus of the
telediastolic cardiac filling and blood
pressure.
Hypocapnia,
made
by
hyperventilation, must be easy and just
short at the beginning of the
management, especially if high peak ICP
suspected. It is important that the
management of patients with severe
trauma covers normoxia, normocapnia,
normoglycemia and normo (optimally)
or mild hypothermia of the head (if no
contraindications, here we are talking
47
about hemorrhage at any location, but

especially the surgical unmanageable,
including intracranial one). Pressurecycled ventilation is usually not
beneficial if an intracranial haematoma
suspected nor in case of hypotension,
especially if it is generated by bleeding
so BiPAP were the most frequent
chosen solution in these situations,
especially for the 18 cases with
pulmonary
contusion.
Using
telemedicine transmisio, especially video
data transmision could assist lower
competency prehospital teams to
decision making or the dispatch center to
send an higher mean of intervention to
support them, always the goal being to
maximize the management in minimum
time as possible[26]
The implications of temperature
control, in fact the issue of hypothermia [27]
- accidental or controlled are management
resources of primary and secondary brain
injury. The use of these means can be
beneficial if it is strictly particularized and
accompanied by a very careful monitoring
of the coagulant status and brain pressure
and hemodynamic parameters (cardiac
index), in order to effectively control the
overloading in conditions of depression of
the contraction force in hypothermia.
The use of controlled hypothermia of
the head may be accepted in conditions of
abdominal trauma coexistence situation only
if PIC is high despite other means of control
and there are no uncontrolled bleeding
sources and the coagulant status is good,
since the trauma team should expect a
dilution coagulopathy given by both the fast
filling and hypothermia. .
In the cases observed in this study,
mortality was - due to several factors whose
control can and should be done in - an
integrated management as follows.
Causes of deaths attributed to

cerebral trauma
External exsanguination added to other
sources of hypovolemia
Respiratory depression / cardiac caused
by the severity of the brain damage
Reduced cerebral perfusion due to mass
effect, diffuse cerebral oedema
spinal trauma
Higher level of Cspine section (above
the C4 )
Upward swelling of the brainstem
Remote complications in the high level
Cspine section
Undervaluing other vital lesions in
patients with myelic sections
abdominal trauma
Acute hypovolemia
Disseminated intravascular coagulation
(massive loss of fibrine) after massive
blood losses
Post-hemorrhagic acute anemia
Toxicoseptic distance complications
arising from abdominal injuries
It is noteworthy that a number of
these causes of death can be missed on a
superficial evaluation due to the incomplete
clinical picture, nonspecific or inconsistent
due to the traumatic associations described
with high visibility in the immediate
perspective on the evolution of the patient
(such as the shock not high lightened and
treated in its "compensated early stages,
can have a dramatic evolution, sometimes
irrecoverable). Others can cause chain
pathophysiological alterations that can
impede the development at distance of the
patient, and thus may alter his chance of
survival, such as hypothermia or crush
syndrome that can have misleading
appearances of gravity which make them
invisible to an unsuspecting and untrained
eyes [28].
48
Others generate over the functional

outcome an echo which cannot be ignored
since it can be devastating and irreversible lesions of the cervical column, compartment
or crush syndrome, acute traumatic ischemia
of limb.
On the other hand, most of the
complications are due to the inability of the
medical team who took the patient to
achieve maximal management of injuries
and obvious clinical disorders, requiring
tactical decisions and complex therapeutic
gestures for which the training, experience
and competence were binding, so that partial
compromise solution were taken that only
protected the patient for reduced time
intervals and in various degrees.
Whatever the causes that generated
the production of these accidents it is
important to mention here that each of them
had an impact not only on the functional
prognosis but also on the vital prognosis, the
patient being under a major risk, which often
is unjustified and avoidable.
It is not be neglected in this chapter
that the immediate mortality in patients with
myelitic lesions of the cervical spine was
7% (due to lesion generated only at the
myelitic level - under 24 hours). It is also
particularly important that there have been
two serious accidents in patients brought to
the ER with trauma score 6 and 8, to whom
the previous attempt to place the nasogastric
tube in craniofacial trauma and abdominal
conditions (with frequent vomiting) led to
Mendelson syndrome and malposition of the
tube respectively in the facial sinuses.
Conclusions
The combination of significant brain injury
and abdominal trauma is over then 40%
from observed patients, meaning that very
significant part of the multiple trauma
patients could have this association, could
have risks that this association are involving,
and could have beneficial proactive
management assessment in sense to decrease
survival chance and functional impairment

due to consequences that this association
leads to.
The occult lesions are missed
diagnosis lesions caused by a multitude of
effects of hidden of symptoms and signs
from clinical syndromes, induced by altered
mental status and decreasing level of
sensibility, which may mask or complicate
certain visceral abdominal injuries.
The survival chance is higher to the
patients with medium TS level but medium
management level protocol compared to
inferior TS level but aggressive, anticipative
and well conducted management strategy.
The therapeutic strategy, following a
series of golden standards gives the
expected results only if it is early, vigorous
and accurate in algorithm, free from the
temptation of the middle way. Beyond the
false security of the induced gestures
thought to be minimally invasive, there are
usually lost benefits, lost time and wasted
resources, with effects difficult or even
impossible to recover in the patient's
economy.
The precocity of the proactive
management starting in prehospital phase of
intervention with high competency medical
emergency team, sometimes aggressive can
earn benefits that otherwise the late conduct
cannot recover, however powerful it may be
(early immobilization of the column, early
airway control, preventing secondary brain
injury).
So early access to accident scene and
concentration of highly specialized medical
resources with advanced training for trauma
and currently involved in a high level
trauma center activity as well as pre-hospital
care must be massive from the beginning for
these types of injuries. More than that,
dispatch center involvement are mandatory
to choose the most appropriate means of
intervention and in the same time the closest
one, or to associate multiple means of
49
intervention from firs aid to mobile

prehospital ICU team to cover long
distances with sequential levels of
management.
The better satisfactory solution was
to decide most often the emergency medical
helicopter intervention directly in scene
(sometimes prefaced by the closest first aid
team). That solution has ensured the highest
level of intervention, identical in complexity
of decision, procedures and protocol with
the trauma center one and in the same time
to maintain all the intervention in ,,golden
hour real terms. The third advantage of this
way of approach are the primary addressing
the appropriate patient to the most
appropriate trauma center, avoiding
successively subsequent transfers between
trauma centers to attain the goals of
management.
The general final conclusion are that
multiple trauma patient with particular
significant both brain and abdominal injury
define a picture with a background of strong
colors that requires classical and well know
attitudes, but a lots of shades that involves
many much specific and specialized
resources that utility, priority, complexity,
risks and possibility of implementation
should to be every time decided based on
serious criteria panel to maximize benefits
and minimize the misdiagnosis and
avoidable deaths.
Conflicts of Interest: Nil
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ISSN No. 2394-3971

ABDOMINAL TRAUMA AND BRAIN INJURY DIFFICULT CONDITION,

Medico Research Chronicles, 2016

Submitted on: January 2016

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Road accidents - 303 cases, of which

Figure 1 Initial trauma scores groups sorted by lesion profile

Medico Research Chronicles, 2016

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We divided the patients according to

their final decision, as well as surgical

Graph 1 - trauma score dinamic to TS

TS EVOLUTION (INITIAL TS 7-1 0)

Graph 2 - Evolution of the trauma score in

Medico Research Chronicles, 2016

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TS EVO LUTION (INITIAL TS 11-1 4)

Graph 3 - Evolution of the trauma score

TS EVOLUTION (INITIAL TS 15-16)

Graph 4 - Evolution of the trauma score in

Studying the collected data in these

of the accident by the bystanders, even if

Medico Research Chronicles, 2016

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carefully because on one hand, the initial

accepts also be incriminated: hypo /

Medico Research Chronicles, 2016

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painful one, as a broken column with

the previous presence of poured ascites

Medico Research Chronicles, 2016

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even in patients aware and cooperative, the

Deciding early if the blood transfusion is

Medico Research Chronicles, 2016

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to its generic indications or not

use of appropriate drug combinations

Medico Research Chronicles, 2016

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about hemorrhage at any location, but

Causes of deaths attributed to

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Others generate over the functional

survival chance and functional impairment

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intervention from firs aid to mobile

Luis CA, Salazar AM (2007) Long-term

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11. Wang H.E., Yealy DM. Out-of-hospital

medicine. Ann Emerg Med. 2002.

Medico Research Chronicles, 2016

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