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Table of Content - Volume 19 Issue 2- August 2021
Prospective study comparing clinical abdominal scoring system(CASS) with blunt abdominal trauma severity scoring(BATSS)
N Sivarajan1*, S K Mohammed wasim2, C Kamalakannan3, Abinav Bhardwaj4, Himanshi Grover5, Sugandh6
1Professor, 2,5,6Postgraduate, 3Assistant Professor, 4Senior Resident, Department of General Surgery, SRM Medical college Hospital and Research centre, INDIA. Email: sivarajandr@yahoo.com
Abstract Background: Abdominal trauma is one of the most common causes among injuries caused mainly due to road traffic accidents. Motor vehicle accidents account for 75 to 80 % of blunt abdominal trauma Blunt abdominal trauma is usually not obvious. The knowledge in the management of blunt abdominal trauma has progressively increasing due to the in-patient data gathered from different parts of the world. In spite of the best techniques and advances in diagnostic and supportive care, the morbidity and mortality remains at large. Methods: This study is a prospective study of blunt abdominal injuries from jan2020 to march 2021 at SRM Medical College. Number of cases studied is 100.After initial resuscitation and achieving, hemodynamic stability, all patients were subjected to careful examination, depending on the clinical findings, the clinical abdominal scoring system score (CASS) was calculated and all patients undergo the FAST ultra sound and plain radiograph of chest and abdomen scan and Blunt abdominal trauma severity score (BATTSS) is calculated then. Decision was taken for further investigations and CT scan if the patient is stable. If patient is hemodynamic unstable the patient is resuscitated and planned for emergency surgery if indicated Patients are followed up for a week to determine their possible need for laparotomy. The documented values of CASS and BATSS were recorded and was analysed with respect to the outcome whether or not the patient needed laparotomy or managed conservatively. Analysis was done using SPSS software. Results: Our study revealed that strong correlation of higher CASS and BATS Scores with increased mortality. The Average CASS score of the operative group was 11.56 with a standard deviation of 2.02. The mean BATS Score of the operative group was 13.4 with a standard deviation of 2.17 The higher scores of both CASS and BATSS needed laparotomy (value of more than 12) with a specificity of 100% for both scoring systems. Keywords: trauma, trauma score, CASS, BATS, trauma severity score, Abdominal injuries, Blunt injury, Emergency department, Blunt abdominal trauma, polytrauma, Revised Trauma Score, Abdominal trauma, laparotomy, Time of presentation
INTRODUCTION Trauma is among the major causes of death around the world, especially in the younger group of population. Abdominal trauma holds the third rank in prevalence after head and chest traumas, with majority of cases being Blunt Abdominal Trauma1. The knowledge in the management of Blunt Abdominal Trauma has progressively increasing due to the inpatient data gathered from different parts of the world. In spite of the best techniques and advances in diagnostic and supportive care, the morbidity and mortality remains at large. The reason for this could be due to the interval between trauma and hospitalization, delay in diagnosis, inadequate and lack of appropriate surgical treatment, post operative complications and associated trauma especially to head, thorax and extremities. The diagnosis of abdominal injury by clinical examination is unreliable. Blunt abdominal trauma requires decisive investigation and management. Ultrasound is the investigation of choice in haemodynamically unstable patients2. Computed tomography can also be used3 but preferred in haemodynamically stable Patients but in addition to being expensive and not easily accessible, it entails irradiation to the patient4,5. Solid organ injury in haemodynamically stable patients can often be managed without surgery. Unstable patients with evidence of intra-abdominal hemorrhage undergo laparotomy immediately6. Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study7. Trauma‑scoring systems have been developed to provide an objective criterion for predicting the morbidity and mortality in trauma patients, which in turn helps in deciding the optimum management strategy including appropriate resource allocation8. In hemodynamically stable patients with blunt abdominal trauma, laparoscopy safely and effectively identifies bowel injuries9. Early recognition of these injuries and timely surgical treatment offers the best prognosis10. In view of increasing number of vehicles and consequently road traffic accidents, this topic has been chosen to study the cases of blunt abdominal trauma with reference to the patients presenting at SRM medical college hospital and research centre , chengalpet to identify the need of laparotomy in cases using a scoring method and identify the most common organs involved in abdomen trauma. OBJECTIVE To determine value of clinical abdominal scoring system (CASS) based on clinical signs , comparing with the Blunt abdomen trauma scoring system (BATSS) in predicting whether a blunt abdomen trauma patient needs laparotomy or not.
MATERIALS AND METHODS This study is a prospective study of blunt abdominal injuries during the period from January 2020 to March 2021 in SRM medical college hospital and research centre, Chengalpet .Number of cases studied is 100. Data were collected from the patients by their clinical history, clinical examination with appropriate investigations, operative findings, operative procedures, complications during the stay in the hospital on those patients who were admitted. The clinical abdominal scoring system score (CASS) was calculated and all patients undergo the FAST ultra sound and plain radiograph of chest and abdomen scan and Blunt abdominal trauma severity score (BATTSS) is calculated then. Inclusion criteria
Exclusion criteria
OBSERVATIONS AND RESULTS the total number of patients admitted with Blunt abdominal trauma by various General surgical Units in SRM MCH andRC was 100. A) AGE INCIDENCE In this series, the majority of the patients belonged to 21-30 years age group, followed by 31-40 years age group.
Table 1:
B) SEX INCIDENCE: In the 100 cases studied, 88 cases were males, with females accounting for only about 12 cases. C) MODE OF INJURY: Road traffic accident was responsible for 61% of blunt abdominal trauma cases, while fall from heights accounted for 25% of cases and blow with blunt object(assault) was responsible for 14% of injuries Table 2:
Table 3:
CLINICAL ABDOMINAL SCORING SYSTEM (CASS) The clinical abdominal scoring is a purely clinical 15 point scoring system. Patients are classified into three groups based on the score
The patients were followed up for a period of 1 week whether the patient is taken up for laparotomy or whether the patient is managed conservatively patients are shifted to FAST scan for further evaluation. CASS SCORE AND OUTCOME OF PATIENTS: The Average CASS score of the non operative group was 6.35 with a standard deviation of 1.56 The Average CASS score of the operative group was 11.56 with a standard deviation of 2.02
Table 4:
ULTRASOUND EXAMINATION: All 100 patients, out of 100 were subjected for ultrasound examination. 37 patients had scan detected solid organ injuries for which they underwent laparotomy and found to have significant injuries. 19 patients had scan detected only free fluid and found to have hollow viscus or solid organ injury at laparotomy. Table 5:
Table 6:
BATSS: BLUNT ABDOMINAL TRAUMA SEVERITY SCORE: This is a 24 point blunt abdominal trauma scoring system. Patients are classified into three groups based on the score
BATSS SCORE AND OUTCOME OF PATIENTS: The mean BATSScore of the non operative group was 3.76 with a SD of 2.32 The mean BATSScore of the operative group was 13.4 with a SD of 2.17 Table 7:
PROCEDURES: Non operative management is gaining increasing acceptance mainly because of the easy availability of better imaging modalities like Ultrasound and CT scan.11 Selective nonoperative management of abdominal visceral lesions is one of the most important and challenging changes that occurred in the traumatized patient care over the last 20 years. The main advantage of this type of management is the avoidance of unnecessary/nontherapeutic laparotomies.12 The various operative procedures carried out among the patients who underwent exploratory laparotomy. Liver injuries were usually graded as I and II. Out of the 13 patients with liver injury, only 6 patients underwent hepatorraphy with gel foam packing and rest of them were treated with gel foam packing alone. Out of 15 patients with splenic injury, 10 patients underwent splenectomy, 3 patients were treated by splenorrhaphy and 2 were managed conservatively. Bowel perforations were treated with 2 layered closure, with only 2 patients requiring resection and anastomosis.13
DISCUSSION Trauma is one among the leading causes of death. The evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. A study done by Ravi Kanth J et al.14, the authors observed that the patients who had sustained blunt abdominal trauma may have sustained injury simultaneously to other systems and it is particularly important to examine for injuries of head, thorax and extremities. Medical management of blunt abdominal trauma (BAT) relies on judging patients for whom laparotomy is mandatory.15 However, difficulty in diagnosing the intra abdominal injury explains the real need for an accurate and in hand method to evaluate the patients who require further surgical interventions. Boutros SM et al.16, out of the 15 patients with intra-abdominal injury, 5 patients had liver injury, 6 patients had splenic injury, 3 patients had renal injury and one patient had intestinal injury. Our study revealed that strong correlation of higher CASS and BATS Scores with increased mortality. The Average CASS score of the operative group was 11.56 with a standard deviation of 2.02. The mean BATS Score of the operative group was 13.4 with a standard deviation of 2.17The higher scores of both CASS and BATSS needed laparotomy (value of more than 12) with a specificity of 100% for both scoring systems. Further it can be concluded that the group with BATS scores less than 8 does not need laparotomy and can be observed after an Ultra sound. Lower BATSS value is found to be significant in ruling out intra-abdominal trauma and thus preventing unwarranted CT investigations.
CONCLUSION It is demostrated in this study that CASS score was significantly higher is patients requiring a laparotomy p(<0.01). Calculations reveal CASS has a specificity of 100% sensitivity of 54%positive predictive value of 100% and negative predictive value of 78.7% In BATS Clinical examination is combined with radiography and USG to obtain this score. Our study report that a value more than 12 can be strong predictor for laparotomy With a specificity of 100% sensitivity of 83.5% positive predictive value of 100% and negative predictive value of 91.3% A value of 12 or more in either scoring system is associated with need of laparotomy and such patients should be planned for laparotomy as soon as the patient is received in the casualty. A value of 8 or less in BATSS scoring systems are associated with no mortality and no need for laparotomy and no need for further imaging after FAST. Hence found to be superior to CASS.
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