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Simultaneous Intracranial and Abdominal Injury: Which Gets Operated on First, and Which Has the Higher Treatment Priority?

Colonel John B. Holcomb

BRIEF ANSWER

Background

Patients who present to the emergency department (ED) with significant intraabdominal hemorrhage and concomitant large intracranial mass lesions are, fortunately, uncommon. These patients typically suffer from blunt vehicular trauma. Often, some element of illicit drug use confounds the hemodynamic and neurologic examinations. These severely ill patients require coordination of efforts by trauma surgeons and neurosurgeons. The main objective is to prevent or promptly treat hypotension, hypoxia, and other secondary brain insults. This goal is best achieved by balancing the devastating consequences of hypotension¹ from continued intraabdominal hemorrhage against those of untreated traumatic mass lesions.

The presence or absence of cavitary hemorrhage must be determined as expeditiously as possible. Although the method utilized will vary at different hospitals and even among different providers within the same hospital, the emphasis must remain on a safe yet rapid evaluation. Ultrasound or diagnostic peritoneal lavage (DPL) is used most commonly, largely because these tests may be performed without patients having to leave the ED. In many centers, obtaining computed tomography (CT) scans of the abdomen and head requires taking patients out of the ED. Such transport may be detrimental in hemodynamically unstable patients. However, the increasing presence of high-speed helical scanners in EDs may reduce the problem of hemodynamic deterioration in the radiology department or CT scanner by allowing extremely rapid evaluation of hemodynamically marginal patients. The ultimate solution to this problem may consist of portable CT scanners that can be wheeled into the ED.

The discussion of shock in the Advanced Trauma Life Support (ATLS) manual divides resuscitation of trauma patients into four categories based on their hemodynamic status and physiologic response to resuscitation.2 The first group is hemodynamically stable, with minimal cavitary hemorrhage and severe head injury. The second group responds to fluid resuscitation and stabilizes at a normal blood pressure. The third group is initially hypotensive and transiently responds to fluid resuscitation, yet soon exhibits a return of hypotension. The fourth group is persistently hypotensive and does not respond to resuscitation. The last two physiologic patterns are consistent with ongoing bleeding and/or exsanguination. Patients’ initial evaluation in the ED and their hemodynamic response to fluid resuscitation will determine whether they receive an emergency operation or a continuing radiologic evaluation followed by a more orderly progression to the OR. In the next section, the relative operative priorities of the intracranial lesion and the abdominal injury are evaluated in each group.

When combined with an operative head injury, a pelvic fracture causing hemodynamic compromise is an ominous finding. These patients require both rapid intervention for their intracranial lesion and external fixation and/or angiographic embolization for the pelvic fracture. Discussion of the timing and staging of these interventions would exceed the space allotted for this review. Also beyond the scope of this brief outline is the optimal combination of abdominal ultrasound, DPL, and CT in the evaluation of blunt abdominal trauma. The author routinely utilizes all three modalities because their distinct advantages suggest that they should be used in a complementary fashion.