Latest progress of research on acute abdominal injuries

16 Journal of Acute Disease 2016; 5(1): 16–21 H O S T E D BY Contents lists available at ScienceDirect Journal of Acute Disease journal homepage: www.jadweb.org Review article http://dx.doi.org/10.1016/j.joad.2015.07.003 Latest progress of research on acute abdominal injuries Ionut Negoi1,2*, Sorin Paun1,2, Bogdan Stoica2, Ioan Tanase2, Mihaela Vartic2, Ruxandra Irina Negoi1, Sorin Hostiuc1,3, Mircea Beuran1,2 1 Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest, Romania 2 Emergency Hospital of Bucharest, Bucharest, Romania 3 National Institute of Legal Medicine Mina Minovici, Bucharest, Romania A R TI C L E I N F O ABSTRACT Article history: Received 2 Mar 2015 Received in revised form 22 May 2015 Accepted 26 Jul 2015 Available online 9 Oct 2015 Major abdominal trauma, both blunt and penetrating, is commonly seen nowadays, being particularly difficult to manage due to the frequent altered mental status of the patients and severity of associated injuries. The review article aims to make an uptodate study of the current strategies for therapeutic approach of abdominal injuries in polytrauma setting. Review of the medical literature is up to 2015, by using the PubMed/Medline, Science Direct, Cochrane Library and Web of Science databases. We have used different combinations of the keywords of “abdominal trauma”, “liver”, “spleen”, “renal”, to review the reference list of retrieved articles for further relevant studies. Nowadays, we are facing a major change in abdominal trauma therapeutic approach, due to the continuous extending indications and very high successful rate of selective nonoperative management, completed or not with minimally invasive techniques like angiography and angiographic embolization. New imaging methods offer a high-quality characterization of solid organ injuries, being a secure support for decision algorithm in polytrauma patients. After a continuous decrease in number of laparotomies for trauma, new techniques should be developed for maintaining and developing the trauma surgeons' skills. According to the current standards, for a low morbidity and mortality, the trauma patients may be approached by a multidisciplinary and experienced trauma team. Even if nonoperative management is continuously expanding, this may be applied only by a trained and skillful trauma surgeon, who is able to perform difficult surgical techniques at any moments. Keywords: Polytrauma Abdominal injuries Management 1. Introduction Like in all other European countries, blunt abdominal trauma is commonly seen in Romanian Emergency Departments[1]. These injuries are particularly difficult to manage due to the frequent altered mental status and associated injuries, and that the patients are often presented with a complex clinical picture of head, thoracic, abdominal and limb trauma[2]. The penetrating stab and gunshot wounds are much less common than blunt injuries compared to United States of America or South Africa[3] *Corresponding author: Ionut Negoi, MD, PhD, General Surgery Department, Emergency Hospital of Bucharest, No 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania. Tel: +40 215992308 E-mail: [email protected] Peer review under responsibility of Hainan Medical College. Foundation Project: Supported by the European Social Fund and by the Romanian Government, under contract number POSDRU/159/1.5/S/137390. In a 30-month prospective polytrauma study from our hospital, the most common were blunt injuries in 92.8% of cases and penetrating trauma in only 7.2% of cases. Most severe trauma was caused by road accidents (61.9%), either as drivers or an occupant of a vehicle or by vehicle-pedestrian collision. Motorcycle accidents were found in 2% of cases. They were followed by falls and human aggressions (15.0% and 15.6% respectively). Occupational injuries were the least common, being encountered in 4.8% and autoaggressions in 0.7% of cases respectively[4]. The prevalence of abdominal organ injuries among patients with blunt trauma examined in the Emergency Departments is approximately 13% of cases, the spleen being damaged in over 60% of these cases[5]. Although there are substantial diagnostic challenges, from a surgical perspective, only 4.7% of cases require therapeutic laparotomy or angiographic embolization[5]. The selective nonoperative management (SNOM) of abdominal visceral lesions is one of the most important and 2221-6189/Copyright © 2016 Hainan Medical College. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Ionut Negoi et al./Journal of Acute Disease 2016; 5(1): 16–21 challenging changes that occurred in the traumatized patients over the last 20 years, and the main advantage is the avoidance of an unnecessary or non-therapeutic laparotomy. More than 95% of blunt abdominal injuries may be nonoperatively managed, with a morbidity similar to or even lower than operative treatment[6]. Currently, the resuscitation of the trauma patients can be divided into two time periods: the 10 platinum minutes and the golden hour. During the 10 platinum minutes, the prehospital trauma team should address the airways as well as hinder the exsanguination and the critical patients should be transported from the trauma scenes. During the golden hour, the hospital trauma team should identify all the trauma lesions and address all life-threatening injuries[7]. Although polytrauma patients represent only 10% of trauma victims, they account for 50% of in-hospital mortality. The most frequent injured body areas in multi-trauma patients are the limbs and pelvis, but abdominal and thoracic lesions are strongly correlated with mortality in younger trauma victims[8,9]. The polytrauma deaths are generated by cranial injuries in 40%– 50% of cases, by hemorrhage in 30%–35% and by multiple organ failure in 5%–10% of cases[9]. The clinical exam of abdominal injuries, depending on the clinical scenario, may be completed with the following diagnostic methods: peritoneal aspiration, abdominal ultrasonography, computed tomography (CT) and angiography. According to the meta-analysis of Nishijima et al., the intraabdominal injuries are suggested by the presence of the seat belt sign [likelihood ratio (LR) range, 5.6–9.9], rebound tenderness (LR, 6.5), hypotension (LR, 5.2), abdominal distension (LR, 3.8), and abdominal guarding (LR, 3.7)[5]. The intraperitoneal free fluid or organ injuries on abdominal ultrasonography overpasses the accuracy of history and physical exam (LR, 30.0). The workup suggests abdominal visceral injuries when there is a base deficit less than −6 mEq/L (LR, 18.0), increased liver transaminases (LR range, 2.5–5.2), hematuria (LR range, 3.7–4.1), anemia (LR range, 2.2–3.3) and abnormal thoracic X-ray (LR range, 2.5–3.8)[5]. It is very important to recognize that overlooked injuries and delayed diagnosis are still common problems in the nowaday management of polytrauma patients[10]. After a review of the literature, Pfeifer and Pape found a widespread distribution of missed and delayed diagnosis incidence (1.3%–39.0%), as much as 22.3% of patients with missed injuries having significant missed lesions. The authors stress the importance of a standardized tertiary trauma survey for earlier detection of clinically significant missed injuries[11]. 2. Imagistic workup Ultrasonography – focused abdominal sonography for trauma (FAST) performed by radiologists, emergency medicine physicians or trauma surgeons is a rapid and highly accurate method for detecting haemoperitoneum[12,13]. Its valuable role is especially for haemodynamic compromise patients[14]. As FAST can miss or underestimate the degree of injury, a CT examination is recommended in haemodynamically stable patients with negative FAST[15–17], because of the recommendation of Miller et al.: not so fast[18]. CT is the most informative radiological technique for head and abdomino-pelvic trauma. During the latest decade, the major developments of CT technology, such as higher spatial 17 resolution, faster image acquisition and reconstruction, and improved patient safety, made the “panscan” the fundamental element in early evaluation and decision-making algoritm[19]. An important but still less standardized use of CT examination is its ability to predict failure of SNOM for abdominal visceral lesions. Although the medical literature presents some imagistic parameters that correlate with SNOM failure, there is no a diagnostic algorithm for selecting patients who will benefit from SNOM. In our trauma center, the abdominal visceral lesions of high grade [grades III, IV or V according to organ injury scale (OIS)] or lesions with actively contrast extravasation on emergency CT scan, are evaluated through an emergency diagnostic and/or therapeutic angiography[20]. Ochsner shows that the presence of a contrast pool in liver trauma means active bleeding and significantly correlates with need for surgery[21]. For splenic injuries, the contrast extravasation in the arterial phase is associated with SNOM failure[21]. We consider contrast extravasation or high-grade visceral lesions, in a haemodynamically stable patient, as an indication for angiography and not for emergency laparotomy[22–24]. Angiography has evolved dramatically in the recent years, first as an assistance of the operative approach rather than the nonoperative one[25]. The angiographic embolization can be successfully done in liver, spleen, kidney or pelvic bleeding[22,26,27]. In their study, Velmahos et al. presented a success rate of 91% for angiographic hemostasis in these conditions[28]. 3. Damage control surgery The hemorrhagic shock is generated by a unique factor, the massive acute blood loss that causes a complex and heterogeneous clinical picture[29]. Blood et al. analyzed the hospital records of 210 fatal combat casualties who died after the medical treatment was started. About 25% of the deaths were produced by massive exsanguination and were beyond current medical resources, but 19% of additional deaths were preventable, of which 10% were due to thoracic exsanguination and 19% to peripheral exsanguination[30]. Bailout surgery or damage control surgery was one of the major changes in the thinking of trauma surgery during the last 20 years, challenging the traditional concept of definitive onestep surgery[31]. Nowadays, trauma surgeons have evolved surgical techniques and protocols for managing more and more severe thoracic, abdominal, extremity and peripheral vascular injuries according to principles of damage control[32,33]. Damage control laparotomy is usually performed in highgrade liver and major vascular injuries[34]. Major liver injuries should be explored after inflow occlusion by using the Pringle maneuver, surgical hemostasis through direct vessel ligation in depth of the laceration and the abbreviated technique ended with compression of the liver lesions between packs. We should stress that packing is only an adjunctive measure to be performed only after the hemostasis of the major hepatic vessel(s). Major vascular injuries can be approached by using a combination of different techniques: (a) ligation of the bleeding vessel, excepting the aorta or the proximal superior mesenteric artery and retrohepatic vena cava; (b) temporary shunting of the vessel, even with a chest tube. 18 Ionut Negoi et al./Journal of Acute Disease 2016; 5(1): 16–21 Damage control thoracotomy is performed for penetrating thoracic injuries through a fifth anterolateral intercostal space with an aim to find out the bleeding source, to rule out the cardiac tamponade and to cross clamp the descending aorta[35–37]. Damage control orthopedics should be used for rapid and temporary stabilizations of the pelvic and femoral fractures, usually with an external fixator[38,39]. 4. Liver trauma The surgical approach of a high-grade liver injury represents one of the most challenging aspects of trauma surgery, due to its massive bleeding in a difficult position to control area, associated with a profoundly altered physiology, without the benefits of a clear anatomy as obtainable for elective hepatic resections. Over the past 20 years, the nonoperative management of liver injuries became the dominant therapeutic strategy[40]. The hemodynamically unstable patient with a liver trauma should be transported to the operating room for emergency laparotomy and rapid control of the bleeding. After a large midline laparotomy, the surgeons have to pack all the four quadrants of the abdomen. If a liver injury is suspected, the right upper quadrant should be explored last[41]. If the hemostasis was achieved after packing and the physiology of the patient is altered, the procedure may be one of damage controls, and the patient will be returned into the operating room after 36–72 h. There are many advanced techniques for liver hemostasis, even for major liver resections, that can be used by the trauma surgeons and adapted to a specific patient with a specific physiological status[42]. The surgeon facing a liver trauma in a hemodynamically stable patient, without signs of peritoneal irritation should apply the standard of care, represented by nonoperative management, regardless of the severity of injury (Figure 1)[43]. In high-grade liver lesions addressed nonoperatively, severe complications may occur like ongoing bleeding, bile collections, pseudoaneurysm formation with haemobilia or gallbladder necrosis. For their management, the surgeon should use minimally invasive techniques like angiography, CT-guided drainage or laparoscopic drainage. In a study from our trauma center[44], the liver was injured in 50 out of 207 cases (24.2%), being the major abdominal trauma in 38 patients (18.4%). According to OIS classification of American Association for the Surgery of Trauma (AAST), 10 patients (26.3%) had grade I liver injury, 12 (31.6%) grade II lesions, 11 (28.9%) grade III and 5 (13.2%) grade IV. Out of these injuries, 19 (50%) were successfully nonoperatively managed, 18 (47%) were surgically explored and the failed nonoperative management was for one case (3%) due to bleeding (Figure 2). Surgical approach by laparotomy was in 11 cases (73.3%) and laparoscopy in 4 cases (liver was the major injury in two major cases) (26.7%). In one case, laparoscopy was converted to open approach. About 70% of laparotomies and 75% of laparoscopies were non-therapeutic. 5. Splenic trauma SNOM replaced the methods for spleen conservation like splenorrhaphy, and up to 70% of splenic injuries are now being treated nonoperatively[45]. Initially, complex splenic injuries, the spleen with a pre-existing pathology, needed for transfusion, and patients with severe brain injury, aged over 55 years were considered inappropriate for SNOM; today, however, these conditions are not universally accepted(45,46]. Currently, it is considered that SNOM can be applied safely in patients over 55 years and in carefully selected patients with severe head trauma[6,47]. According to a recent meta-analysis of predictive factors and outcome for failure of SNOM in blunt splenic trauma, the following factors may lead to early identification of patients at high risk for SNOM failure, who will benefit from splenic angioembolization instead: AAST scores, size of haemoperitoneum, age and injury severity score[48]. The angiographic embolization of splenic artery is a very useful tool for achieving hemostasis, but there are concerns regarding the immune function of the angioembolized spleen. Walusimbi et al., in a study analyzed the circulating cellular and humoral elements of immune function following splenic arterial embolization or splenectomy in trauma patients[49], and found that splenic embolization for trauma did not affect total Tlymphocytes, total helper T-lymphocytes, total suppressor Tlymphocytes, complements C3 and C4 or propending concentrations. The evidence supports the idea that systemic immune function is not impaired by the splenic arterial SNOM OM 3% FNOM 47% 50% Figure 1. Bleeding at the level of the right lobe of the liver treated by angioembolization. RHA: Right hepatic artery. Figure 2. Therapeutic approach of liver injuries in polytrauma patients in our center. OM: Operative management; FNOM: Failed nonoperative management. 19 Ionut Negoi et al./Journal of Acute Disease 2016; 5(1): 16–21 embolization[49]. In the same study from our trauma center[44], the spleen was injured in 131 (63.3%) out of 207 trauma patients, being the most severe abdominal injury in 95 patients (45.9%). According to OIS classification of AAST, 14 patients (14.7%) had grade I splenic injury, 42 (44.2%) grade II, 23 (24.2%) grade III, 15 (15.8%) grade IV and 1 (1.1%) grade V. Out of these injuries, 55 (57%) were successfully managed nonoperatively, 29 (31%) were approached by an operative approach and in 11 patients (12%), the initial nonoperative management failed (Figure 3). Surgical approach by laparotomy was in 26 cases (89.7%) and by laparoscopy in 4 cases (1 case totally laparoscopic, three cases converted to open approach). Splenic surgery was conservative in 11 cases (37.9%) and splenectomy in 13 cases (44.8%). In 5 cases (17.2%), there was a non-therapeutic laparotomy. SNOM OM 25% 75% Figure 4. Therapeutic approach of renal injuries in polytrauma patients in our center. OM: Operative management. 6. Renal trauma The kidney is a very suitable organ for SNOM, with an overall success rate of 90% and 50% in grade V lesions[50,51]. Renal injuries of increasing grade were addressed nonoperatively, given the much higher rate of nephrectomy in surgical group (35.0% versus 12.6%[52,53]). SNOM became the standard treatment for I-III renal injuries[6,54]. Elashry and Dessouky support the conservative management of grade IV blunt renal parenchymal injuries in the absence of hemodynamic instability of renal origin[55]. Out of 57 patients with grade IV and 15 patients with grade V renal injuries, 70.8% (48 for grade IV and 3 for grade V) were managed conservatively, with lower transfusion requirements, shorter hospital stays and fewer complications[55]. Umbreit et al. showed that surgical exploration could be avoided in over 72% of grade IV renal lesions, with a rate of, at least partial, kidney salvage of 95%[56]. We have found that kidney was injured in 30 cases (14.6%), being the major abdominal lesion only in 8 cases (3.9%)[4]. According to OIS classification of AAST, there were 2 (25.0%) grade I patients, 3 (37.5%) grade II patients, 1 (12.5%) grade III, 1 (12.5%) grade IV and 1 (12.5%) grade V. Out of these 8 cases, 6 (75%) were successful nonoperatively managed and 2 by operative approach. There was no failure for nonoperative management (Figure 4). 7. Conclusions Nowadays, we are facing a major change in therapeutic approach for abdominal trauma due to the continuous extending indications and very high successful rate of SNOM, completed or not with minimally invasive techniques like angiography and angiographic embolization. After a continuous decrease in number of laparotomies for trauma, new techniques should be developed for maintaining and developing the trauma surgeons' skills. Conflict of interest statement The authors report no conflict of interest. Acknowledgments This paper was supported by the Sectoral Operational Programme Human Resources Development, financed by the European Social Fund and by the Romanian Government, under contract number POSDRU/159/1.5/S/137390 for Dr. Ionut Negoi. All authors contributed equally to this study. References SNOM OM FNOM 12% 31% 57% Figure 3. Therapeutic approach of splenic injuries in polytrauma patients in our center. OM: Operative management; FNOM: Failed nonoperative management. [1] Beuran M, Stoica B, Negoi I, Tanase I, Gaspar B, Turculeţ C, et al. Trauma registry-a necessity of modern clinical practice. Chirurgia (Bucur) 2014; 109(2): 157-60. [2] Kouris G, Hostiuc S, Negoi I, Curca GC. Sepsis and lower limb fractures in road traffic accidents. Rom J Leg Med 2012; 20: 203-6. [3] Ball CG. Current management of penetrating torso trauma: nontherapeutic is not good enough anymore. Can J Surg 2014; 57(2): E36-43. [4] Beuran M, Negoi I. [Selective nonoperative management of abdominal visceral lesions in polytrauma patients]. Bucharest: Romanian Academy Publishing House; 2013. Romanian. [5] Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA 2012; 307(14): 1517-27. [6] Beuran M, Negoi I, Paun S, Runcanu A, Venter D, Iordache F, et al. [Selective nonoperative management of solid abdominal visceral lesions]. Chirurgia (Bucur) 2010; 105(3): 317-26. Romanian. 20 Ionut Negoi et al./Journal of Acute Disease 2016; 5(1): 16–21 [7] Beuran M, Paun S, Gaspar B, Vartic N, Hostiuc S, Chiotoroiu A, et al. Prehospital trauma care: a clinical review. Chirurgia (Bucur) 2012; 107(5): 564-70. [8] Kouris G, Hostiuc S, Negoi I. Femoral fractures in road traffic accidents. Rom J Leg Med 2012; 20(4): 279-82. [9] Paun S, Beuran M, Negoi I, Runcanu A, Gaspar B. [Traumaepidemiology: where are we today?]. Chirurgia (Bucur) 2011; 106(4): 439-43. Romanian. [10] Chen CW, Chu CM, Yu WY, Lou YT, Lin MR. Incidence rate and risk factors of missed injuries in major trauma patients. Accid Anal Prev 2011; 43(3): 823-8. [11] Pfeifer R, Pape HC. Missed injuries in trauma patients: a literature review. Patient Saf Surg 2008; 2: 20. [12] Brooks A, Davies B, Smethhurst M, Connolly J. Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum. Emerg Med J 2004; 21(5): e5. [13] Arhami Dolatabadi A, Amini A, Hatamabadi H, Mohammadi P, Faghihi-Kashani S, Derakhshanfar H, et al. Comparison of the accuracy and reproducibility of focused abdominal sonography for trauma performed by emergency medicine and radiology residents. Ultrasound Med Biol 2014; 40(7): 1476-82. [14] Smith ZA, Wood D. Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability. Emerg Med J 2014; 31(4): 273-7. [15] Ochsner MG, Knudson MM, Pachter HL, Hoyt DB, Cogbill TH, McAuley CE, et al. Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis. J Trauma 2000; 49(3): 505-10. [16] Schnüriger B, Kilz J, Inderbitzin D, Schafer M, Kickuth R, Luginbühl M, et al. The accuracy of FAST in relation to grade of solid organ injuries: a retrospective analysis of 226 trauma patients with liver or splenic lesion. BMC Med Imaging 2009; 9: 3. [17] Natarajan B, Gupta PK, Cemaj S, Sorensen M, Hatzoudis GI, Forse RA. FAST scan: is it worth doing in hemodynamically stable blunt trauma patients? Surgery 2010; 148(4): 695-701. [18] Miller MT, Pasquale MD, Bromberg WJ, Wasser TE, Cox J. Not so FAST. J Trauma 2003; 54(1): 52-9; discussion 59-60. [19] Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology 2012; 265(3): 678-93. [20] van der Vlies CH, Saltzherr TP, Wilde JC, van Delden OM, de Haan RJ, Goslings JC. The failure rate of nonoperative management in children with splenic or liver injury with contrast blush on computed tomography: a systematic review. J Pediatr Surg 2010; 45(5): 1044-9. [21] Ochsner MG. Factors of failure for nonoperative management of blunt liver and splenic injuries. World J Surg 2001; 25(11): 1393-6. [22] Sabe AA, Claridge JA, Rosenblum DI, Lie K, Malangoni MA. The effects of splenic artery embolization on nonoperative management of blunt splenic injury: a 16-year experience. J Trauma 2009; 67(3): 565-72; discussion 571-2. [23] Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ 3rd, et al. Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg 2012; 72(5): 1127-34. [24] Bessoud B, Denys A, Calmes JM, Madoff D, Qanadli S, Schnyder P, et al. Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization? AJR Am J Roentgenol 2006; 186(3): 779-85. [25] Roudsari BS, Psoter KJ, Padia SA, Kogut MJ, Kwan SW. Utilization of angiography and embolization for abdominopelvic trauma: 14 years' experience at a level I trauma center. AJR Am J Roentgenol 2014; 202(6): W580-5. [26] Mohr AM, Lavery RF, Barone A, Bahramipour P, Magnotti LJ, Osband AJ, et al. Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma 2003; 55(6): 1077-81; discussion 1081-2. [27] Breyer BN, McAninch JW, Elliott SP, Master VA. Minimally invasive endovascular techniques to treat acute renal hemorrhage. J Urol 2008; 179(6): 2248-52; discussion 2253. [28] Velmahos GC, Chahwan S, Falabella A, Hanks SE, Demetriades D. Angiographic embolization for intraperitoneal and retroperitoneal injuries. World J Surg 2000; 24(5): 539-45. [29] Bouglé A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hemorrhagic shock. Ann Intensive Care 2013; 3: 1. [30] Blood CG, Puyana JC, Pitlyk PJ, Hoyt DB, Bjerke HS, Fridman J, et al. An assessment of the potential for reducing future combat deaths through medical technologies and training. J Trauma 2002; 53(6): 1160-5. [31] Weber DG, Bendinelli C, Balogh ZJ. Damage control surgery for abdominal emergencies. Br J Surg 2014; 101(1): e109-18. [32] Puyana JC, Tisherman SA, Peitzman AB. Current concepts in the diagnosis and management of hemorrhagic shock. In: Asensio JA, Trunkey DD, editors. Current therapy of trauma and surgical critical care. Philadelphia: Mosby Elsevier; 2008, p. 437-45. [33] Mohr AM, Asensio JA, Karsidag T, García-Núñez LM, Petrone P, Morehouse AJ, et al. Exsanguination: reliable models to indicate damage control. In: Asensio JA, Trunkey DD, editors. Current theraphy of trauma and surgical critical care. Philadelphia: Mosby Elsevier; 2008, p. 445-9. [34] Davis KA, Luchette FA. Surgical techniques for thoracic, abdominal, pelvic, and extremity damage control. In: Asensio JA, Trunkey DD, editors. Current therapy of trauma and surgical critical care. Philadelphia: Mosby Elsevier; 2008, p. 449-53. [35] Garcia A, Martinez J, Rodriguez J, Millan M, Valderrama G, Ordoñez C, et al. Damage-control techniques in the management of severe lung trauma. J Trauma Acute Care Surg 2015; 78(1): 45-50; discussion 50-1. [36] O'Connor JV, DuBose JJ, Scalea TM. Damage-control thoracic surgery: management and outcomes. J Trauma Acute Care Surg 2014; 77(5): 660-5. [37] Mackowski MJ, Barnett RE, Harbrecht BG, Miller KR, Franklin GA, Smith JW, et al. Damage control for thoracic trauma. Am Surg 2014; 80(9): 910-3. [38] Lichte P, Kobbe P, Dombroski D, Pape HC. Damage control orthopedics: current evidence. Curr Opin Crit Care 2012; 18(6): 64750. [39] Amin OA, Mustafa K, Hussein H. Damage control orthopedic surgery (DOC): is there an influence on outcome? Int J Health Sci (Qassim) 2011; 5(2 Suppl 1): 39-40. [40] Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73(5 Suppl 4): S288-93. [41] Schecter WP, Hirshberg A. Injuries to the liver and biliary tract. In: Jarnagin W, editor. Blumgart's surgery of the liver, pancreas and biliary tract. 5th ed. Philadelphia: W.B. Saunders; 2012, p. 180614. [42] Jiang H, Wang J. Emergency strategies and trends in the management of liver trauma. Front Med 2012; 6(3): 225-33. [43] McVay MR, Kokoska ER, Jackson RJ, Smith SD. Throwing out the “grade” book: management of isolated spleen and liver injury based on hemodynamic status. J Pediatr Surg 2008; 43(6): 1072-6. [44] Gaspar B, Negoi I, Paun S, Hostiuc S, Ganescu R, Beuran M. Selective nonoperative management of abdominal injuries in polytrauma patients: a protocol only for experienced trauma centers. Maedica (Buchar) 2014; 9(2): 168-72. [45] Velmahos GC, Chan LS, Kamel E, Murray JA, Yassa N, Kahaku D, et al. Nonoperative management of splenic injuries: have we gone too far? Arch Surg 2000; 135(6): 674-9; discussion 679-81. [46] Krause KR, Howells GA, Bair HA, Glover JL, Madrazo BL, Wasvary HJ, et al. Nonoperative management of blunt splenic injury in adults 55 years and older: a twenty-year experience. Am Surg 2000; 66(7): 636-40. [47] Siriratsivawong K, Zenati M, Watson GA, Harbrecht BG. Nonoperative management of blunt splenic trauma in the elderly: does age play a role? Am Surg 2007; 73(6): 585-9; discussion 590. Ionut Negoi et al./Journal of Acute Disease 2016; 5(1): 16–21 [48] Bhangu A, Nepogodiev D, Lal N, Bowley DM. Meta-analysis of predictive factors and outcomes for failure of non-operative management of blunt splenic trauma. Injury 2012; 43(9): 1337-46. [49] Walusimbi MS, Dominguez KM, Sands JM, Markert RJ, McCarthy MC. Circulating cellular and humoral elements of immune function following splenic arterial embolisation or splenectomy in trauma patients. Injury 2012; 43(2): 180-3. [50] Toutouzas KG, Karaiskakis M, Kaminski A, Velmahos GC. Nonoperative management of blunt renal trauma: a prospective study. Am Surg 2002; 68(12): 1097-103. [51] Eassa W, El-Ghar MA, Jednak R, El-Sherbiny M. Nonoperative management of grade 5 renal injury in children: does it have a place? Eur Urol 2010; 57(1): 154-61. 21 [52] Alonso RC, Nacenta SB, Martinez PD, Guerrero AS, Fuentes CG. Kidney in danger: CT findings of blunt and penetrating renal trauma. Radiographics 2009; 29(7): 2033-53. [53] Harris AC, Zwirewich CV, Lyburn ID, Torreggiani WC, Marchinkow LO. Ct findings in blunt renal trauma. Radiographics 2001; 21 Spec No: S201-14. [54] Stawicki SP. Trends in nonoperative management of traumatic injuries: a synopsis. OPUS 12 Scientist 2007; 1(1): 19-35. [55] Elashry OM, Dessouky BA. Conservative management of major blunt renal trauma with extravasation: a viable option? Eur J Trauma Emerg Surg 2009; 35(2): 115-23. [56] Umbreit EC, Routh JC, Husmann DA. Nonoperative management of nonvascular grade IV blunt renal trauma in children: metaanalysis and systematic review. Urology 2009; 74(3): 579-82.