Elsevier

Injury

Volume 45, Issue 1, January 2014, Pages 88-94
Injury

A haemoperitoneum does not indicate active bleeding in the peritoneum in 50% of hypotensive blunt trauma patients: A study of 110 severe trauma patients

https://doi.org/10.1016/j.injury.2012.05.018Get rights and content

Abstract

Background

We hypothesised that in blunt trauma patients with haemodynamic instability and haemoperitoneum on hospital admission, the haemorrhagic source may not be confined to the peritoneum. The purpose of this study was to describe the incidence and location of bleeding source in this population.

Methods

The charts of trauma patients admitted consecutively between January 2005 and January 2010 to our level I Regional Trauma Centre were reviewed retrospectively. All hypotensive patients presenting a haemoperitoneum on admission were included. Hypotension was defined by a systolic blood pressure ≤ 90 mm Hg. The haemoperitoneum was quantified on CT images or from operative reports as moderate (Federle score < 3 or between 200 and 500 ml) or large (Federle score ≥ 3 or >500 ml). Active bleeding (AB) was defined as injury requiring a surgical or radiologic haemostatic procedure, regardless of origin (peritoneal (PAB) or extraperitoneal (EPAB)).

Results

Of 1079 patients admitted for severe trauma, 110 patients met the inclusion criteria. Seventy-eight (71%) were male, mean age 35.3 (SD 19) years and mean ISS 36.5 (SD 20.5). Among the 91 patients who had AB, 37 patients (41%) had PAB, 34 (37%) had EPAB and 20 had both (22%). Forty-eight (53%) of them had moderate haemoperitoneum and 43 (47%) had large haemoperitoneum. A large haemoperitoneum had positive predictive value for PAB of 88% (95% CI 75–95%) and negative predictive value of 65% (95% CI 49–79%). The corresponding values in the subgroup of patients with EPAB were 65% (95% CI 38–86%) and 76% (95% CI 59–88%).

Conclusion

Haemoperitoneum was associated with PAB in only 52% of hypotensive blunt trauma patients and 63% of bleeding patients. In contrast, 59% of bleeding patients had at least one EPAB. The screening of a haemoperitoneum as a marker of active haemorrhagic source may be confusing and lead to misdiagnosis and inappropriate strategy. Clinician should exclude carefully the presence of any EPAB explaining haemorrhagic shock, before to decide haemostatic treatment.

Section snippets

Background

On admission of a patient with blunt exsanguinating trauma, the aim of initial management is to localise and control the active haemorrhage as soon as possible.1, 2 Rationally, in a patient with blunt trauma presenting haemodynamic instability associated with a free peritoneal effusion, the obvious source of exsanguination is the peritoneum. As a consequence, the Focus Assessment with Sonography for Trauma (FAST) is the pivotal diagnostic used to localise the source of bleeding and guide

Study design and patients

The database of 1079 patients admitted consecutively for trauma in the trauma intensive care unit at our level I Regional Trauma Centre between January 2005 and January 2010 was reviewed retrospectively. These patients were suspected for a severe trauma by a prehospital medical team (SAMU system) and were directly hospitalised in our trauma department according to the French guidelines of prehospital medical triage.6 All blunt trauma patients aged 16 years or over with a haemodynamic

Population characteristics and initial management (n = 110)

During this 5-year period, 115 patients admitted to our trauma department were diagnosed with a moderate or large haemoperitoneum associated with a systolic blood pressure lower than 90 mm Hg within the first 15 min after admission. Five patients died before exploration and were excluded because of a lack of data. Of the 110 remaining patients, 78 (71%) were male, mean age 35.3 (SD 19) years. Mechanisms of trauma were: a motor vehicle crash in 92 patients, 7 pedestrians struck by a motor vehicle,

Discussion

The main finding of our study is that in severe blunt trauma patients, the source of bleeding can be multiple. In this population of blunt trauma patients presenting hypotension and haemoperitoneum on admission, the clinical situation instinctively guides us to an active haemorrhage from a peritoneal source. However, only 52% of our hypotensive patients had PAB and 49% had an EPAB (Fig. 1). Therefore, why did so many patients in this caricatural clinical scenario have no PAB? Why so many

Conclusion

The half of hypotensive blunt trauma patients with haemoperitoneum on admission does not have AB of peritoneal origin. In severe blunt trauma patients, the source of bleeding can be multiple. In such cases, a haemoperitoneum may be confusing and mask the real origin of AB, causing delay in necessary haemostatic treatment, which may be life threatening. As expected, a large haemoperitoneum is strongly associated with the presence of PAB in bleeding patients, although 12% of large haemoperitoneum

Conflict of interest

The authors have no conflicts of interest to declare.

Acknowledgements

The authors wish to thank Sophie Bringuier and Dorine Neveu for their contributions to the statistical analysis of this study.

References (24)

  • M. Federle et al.

    Hemoperitoneum studied by computed tomography

    Radiology

    (1983)
  • Charbit J, Millet I, Martinez O, Roustan JP, Merigeaud S, Taourel P, et al. Does the size of the hemoperitoneum help to...

    • Cited by (0)

    View full text
    Copyright © 2012 Elsevier Ltd. All rights reserved.