CURRENT MANAGEMENT ACCORDING TO ATLS AND AAST AND WSES CLASSIFICATION

1. Principles Of Trauma
Management
Abdominal Trauma
Hepatobiliary And Splenic Trauma
Moderator
Prof Vinod Jain
Dr. Geetika Nanda Singh
Dr.Parijat Suryavanshi
Dr.Ashish Chaubey

2. Presentation Statement
Unrecognized abdominal and pelvic
injuries continue to be A cause of
preventable death

3. External Landmarks

4. Classification of injuries
 Blunt trauma
 Penetrating trauma
 Iatrogenic trauma

5. Mechanism of Injury
When should you suspect abdominal
injury?
• Speed
• Point of impact
• Intrusion
• Safety devices
• Position
• Ejection
• Weapon
• Distance
• Number, location of wounds
• Combined mechanism
Blunt
Penetrating
Explosion

6. Blunt Force Mechanism
• Spleen
• Liver
• Small bowel
• Pelvis
Common Injuries

7. Penetrating Mechanism
• Stab
• Low energy, lacerations
• Gunshot
• Ballistics
• Type of weapon
• Shrapnel
• Shotgun
• Distance from target
• Spread of projectiles
• Explosion / blast
Any Organ at Risk

8. Case Scenario
● 35-year-old male passenger in high-
speed motor vehicle collision
● Blood pressure: 105/80; Pulse: 110;
respiratory rate: 18; GCS Score = 15
● Complaining of pain in Abdomen
What injuries do you suspect,
and how would you manage this patient?

9. Assessment
How do I determine if there is an
abdominal injury?
Physical Exam
• Inspection
• Auscultation
• Percussion
• Palpation
Adjuncts of Primary Survey
• Pelvic x-ray
• C X ray
• FAST
• DPL

10.  Inspection: abrasions, contusions, lacerations,
deformity, entrance and exit wounds to determine
path of injury…………..
(Grey-Turner, Kehr, Balance, Cullen, seat belt sign….)
 Palpation: elicit superficial, deep, or rebound
tenderness; involuntary muscle guarding
 Percussion: subtle signs of peritonitis; tympany in
gastric dilatation or free air; dullness with
hemoperitoneum.
 Auscultation: bowel sounds may be decreased(late
finding).
Physical Examination

11. Physical Examination
• Accuracy Only 60-65%
• Serial Examination- Best Sensitivity And
Negative Predictive Value
• Primary Objective-rapidly Identify The Patient
Who Needs A Laparotomy
• Pulse, Blood Pressure, Capillary Refill And
Urine Output—hypovolemia +
Abdominal Signs
• Most important- Peritonitis

12. HOW TO MANAGE SUCH PATIENT??
PRIMARY SURVEY (ABCDE
approach,damage control
resuscitation,Management of shock)
SECONDAY SURVEY (rapid diagnosis and
prompt management,damage control
surgery)
GRADING OF INJURY(AAST GUIDELINE)
MANAGEMENT OF SPECIFIC INJURIES AS
PER STANDARD PROTOCOL(WSES
GUIDELINE)

13. Primary Survey-ATLS Approach
 A – Intubation may be required if pt. is in
shock, hypotension or unconscious or in need
for ventilation
 B – Watch for hemo-pneumothorax in both
blunt and penetrating thoracoabdominal
injuries
 C – Start with 1 L crystalloid (If active bleeding
you MUST FIND & STOP THE BLEEDING)
 D – May see associated thoracolumbar #es
 E – Watch for other injuries

14. Secondary Survey
History :Not necessary
S.A.M.P.L.E
S: Symptoms:Pain,vomiting,hematuria,hematochezia,
dyspnea, respiratory distress
A: Allergies
M: Medications
L:Last meal
E: Events: Mechanism of injury is important factor

15. Diagnosis & Treatment Priorities
First: recognize presence of shock or intraabdominal
bleeding
Second: start resuscitative measures for shock /
bleeding
Third: determine if abdomen is source for shock or
bleeding
Fourth: determine if emergency laparotomy is needed
Fifth: complete secondary survey, lab, and radiographic
studies to determine if “occult” abdominal injury is
present

16. Resuscitation
 Biggest concern
 Positioning for comfort.
 Apply high-flow oxygen.
 Treat for shock.
 An early rapid assessment of the abdomen
 Rectal examination
 Catheters and tubes
 Administer tetanus prophylaxis and antibiotics as
indicated.

17. Initial Resuscitation
Identify where is the bleeding?
• 4 & On the floor”
 Chest – CXR
 Intraperitoneal abdomen-FAST
 Retroperitoneal abdomen CT scan
 Extremities – (femur #s)-XRs
• Then stop it:
 OR
 Angioembolization
 Pressure
 Reduction & stabilization

18. Damage control resuscitation
• It’s an alternative resuscitation approach to hemorrhagic
shock which involves:
1. Rapid control of surgical bleeding
2. Early and increased use of red blood cells, plasma and platelets in
a 1:1:1 ratio
3. Limitation of excessive crystalloid use
4. Prevention and treatment of hypothermia, hypocalcemia and
acidosis
5. Permissive hypotension. (Hypotensive resuscitation strategies)
• Damage control resuscitation can be applied to
unstable patients who are with life-threatening
hemorrhage & going to need massive transfusion

19. Radiological and Ancillary
diagnostic procedures
 Plain x-ray chest,abdomen,and pelvis
 FAST
 Diagnostic peritoneal lavage – Aspiration
 Local Wound Exploration
 Contrast studies, CT scan.
 Urethro-Cysto-graphy
 IVU
 Angiography

20. Plain films
 Pneumotharax, Haemothorax
 Free air under diaphragm
 Retroperitoneal stippling associated duodenal
injury
 Nasogastric tube, bowel loops in the chest
 Elevation of the both /Single diaphragm
 Lower Ribs # -Liver /Spleen Injury
 In penetrating trauma, injuring trajectory
 Ground Glass Appearance =
Massive Hemoperitoneum
 Obliteration of Psoas Shadow=Retroperitoneal
Bleeding
 Vertebral fracture
XRAY

21. Focused assessment with
sonography for trauma (FAST)
-To diagnose free intraperitoneal
fluid.
-Evaluate solid organ hematoma
-Four areas:
1. Pericardium (subxiphoid)
space2.Perihepatic & hepato-renal
(Morrison’s pouch)
3.Perisplenic
4.Pelvis (Pouch of
Douglas/rectovesical pouch)
sensitivity 60 to 95% for
detecting 100 mL - 500 mL of
fluid
 (E-FAST):
 Add thoracic windows to look for
pneumothorax. Sensitivity 59%,
specificity up to 99% for PTX
The larger the hemoperitoneum, the
higher the sensitivity. So sensitivity
increases for clinically significant
hemoperitoneum.
How much fluid can FAST detect?
250 cc total
100 cc in Morison’s pouch

22. CT SCAN
 Accurate for solid visceral lesions and its grading and intraperitoneal
hemorrhage. Guide nonoperative management of solid organ
damage.
 Sensitivity for solid organ is >95% but for enteric & for diaphragmatic 60%
& for pancreatic 30% (organ specific)
 Noninvassive
 Disadvantages : Contrast allergies
INDICATIONS CONTRAINDICATIONS
Blunt trauma
 Hemodynamically stable
patient
Normal or unreliable
physical examination
Clear indication for
exploratory laparotomy
Hemodynamically
unstable patient
Contrast allergic patient

23. DIAGNOSTIC PERITONEAL LAVAGE
 Useful when USGnot
available
 10ml of blood or enteric
contents (stool,food,
etc.) Constitutes a
positive DPL

24.  Otherpositivefindings-
• >100,000RBCs/mm3 (penetratingtrauma)
• 500WBCs/mm3
• Amylase175IUand
• detectionof bile,bacteriaorfoodfibers.

25. Comparison of DPL,FAST and
CT
DPL FAST CT
DOCUMENTS: BLEEDING FLUID ORGAN
BP STATUS: LOW LOW NORMAL
SENSITIVITY: 98% 82% -97% 92%-98%
SPECTIFITY: LOW(MID80) (MID 90) (HIGH 9O)
DISADVANTAGES:Invasive Op. depended Cost & time

26. Local Wound Exploration
 Formal evaluation of a stab wound under local
anaesthesia in OT
 Penetration of the anterior fascia is considered a
positive LWE

27. LAPAROSCOPY
 Most useful to evaluate penetrating wounds to
thoracoabdominal region in stable patient
 Spec. For diaphragm injury: sensitivity 87.5%, specificity 100%
 Can repair organs via the laparoscope (diaphragm,
solid viscera, stomach, small bowel.)
 Disadvantages:
 Poor sensitivity for hollow visceral injury and
retroperitoneum
 Complications from trocar misplacement

28. Exploratory Laparotomy
Indications For Exploratory Laparotomy Are:
• Either…….Clinical
a. Obvious peritoneal signs on physical examination
b. Hypotension with a distended abdomen
c. Abdominal GSW with peritoneal penetration
d. Abdominal stab wound with evisceration, hypotension, or
peritonitis
• Or………Paraclinical
a. Positive FAST with hemodynamic instability or DPL
b. Findings with any other diagnostic intervention (e.g., chest x-
ray [ruptured diaphragm, pneumoperitoneum], abdominal
ultrasound, abdominal CT, or laparoscopy suggestive of
perforation

29. Damage control
Principles are:
• Control hemorrhage with packing
• Identification of injury
• Prevention and control contamination with
temporary closure
• Avoid further injury
• Resuscitation in the ICU
• Re-exploration and definitive repair once
normal physiology has been restored

30. WHEN TO INSTITUTE ?

31. Before:
ER → OR → DEATH
ICU→OR→ICU
APPROACH
Now:
ER→OR D
→CS

32. Initial Laparotomy In DCS
•Identify the main source of bleeding and stop it
• Perihepatic packing (superior and inferior)
•Small gastrotomies and enterotomies can be rapidly
closed
• Resect non-viable bowel and close the ends
•Minor pancreatic injuries not involving duct- no
treatment
• Distal injury including the panceratic duct- distal
pancreatectomy
• NO pancreaticoduodenectomy (drainage)
• Abdominal closure is rapid and temporary- if there is
any doubt about abdominal compartment syndrome, left it
open (Bogota-bag, vacuum-pack technique, towel clip)

33. MANAGEMENT OF LIVER
AND SPLENIC TRAUMA

34. 3
5

35. WSES GRADE OF LIVER
AAST HEMODYNAMIC WSES GRADE
MINOR I-II STABLE I
MODERATE III STABLE II
SEVERE IV-V STABLE III
I-VI UNSTABLE IV

37. Operative technique/options
• Initial   Explorative Laparotomy
• Temporary control of hemorrhage:
• Why temp?
1. Ongoing hemorrhage, life threatening, no time to
restore circulatory volume.
2. Liver injuries not highest priority.

38. Initial operative management
• Manual compression
• Temporizing packing
-’’Lap sandwich’’
• Portal occlusion
-’’Pringle maneuver’’
• Total hepatic isolation
• Atriocaval shunt

39. Operative management option
• Topical agent
• Electrocautery
• Argon beam coagulator
• Hepatorrhaphy
• Hepatectomy
• Non anatomical resection
• Omental patch
• Damage control packing

40. • Post-operative Angioembolization
• After artery ligation -risk of hepatic necrosis,
bilIoma and abscesses increases
• Portal vein injuries-Primary Repair-ligation to
be avoided
• Liver Packing and a second look or liver
resection are preferable

41. EARLY
PRINGLE
HEMORRHAGE
IVC HEPATIC VEIN
NO
HEMORRHAGE
HEPATIC
ARTERY
LIGATION

42. 6
2

44. • Pringle Manure
– Occludes hepatic
artery & portal vein
– If bleed persists, then it
is hepatic venous
bleed

46. SUTURED LIVER LACERATION

47. Liver packing and hemostatic fibrin gel on liver
surface

48. Omental patch
for liver trauma

49. 7
0

50. Argon
Coagulation
7
1

51. HepaticResections
Parenchymal tissue fragmentation and skeltonization of vascular-biliary
structures with ultrasonic dissector

52. Mesh
rapping
* New technique for grade
III,IV laceration,
tamponading large
intrahepatic hematomas
* Not indicated where
juxtacaval or hepatic vein
injury is suspected

53. Temporary closure
of the abdomen
7
6

54. 7
5

55. SEVERE INJURY
• Three therapeutic options exist: 1) tamponade
with hepatic packing, 2) direct repair (with or
without vascular isolation), and 3) lobar
resection
• Liver packing is the most successful method of
managing severe venous injuries

56. When hepatic vascular exclusion is necessary-
shunting procedures to be done
• Veno-veno bypass (femoral vein to axillary or
jugular vein by pass)
• Atrio-caval shunt bypasse (the retro-hepatic
cava blood through the right atrium)
In cases of liver avulsion or total crush injury-
Total hepatic resection+hepatic
transplantation

57. WSES GRADE OF SPLEEN
AAST HEMODYNAMIC WSES GRADE
MINOR I-II STABLE I
MODERATE III STABLE II
IV-V STABLE III
SEVERE I-V UNSTABLE IV

59. SPLENORRHAPHY
 Parenchyma saving surgery ofspleen
 Thetechnique isdictated by the magnitude of
the splenicinjury
 Nonbleeding grade I splenic injury may require
no furthertreatment.
 1.Superficial hemostatic strategies like
fibrin glue,gel foam,argon beem
coagulation,diathermy,topical thrombin
 2.Non absorbable suturerepair
 3.Absorbable mesh wrap(polygalactin)
 4.Resectional debridement

60. SPLENORRHAPHY

61. SPLENECTOMY
 Indications
-Gr 5injury
-Delayed rupture
-Increasing hematoma
-Clinically unstable of any grade
-Actively bleeding
 Opensplenectomy with midline incision
prefered

62. AUTOTRANSPLANTATION
 Implanting multiple 1-mm slices of the spleen
in the omentum after splenectomy.
This technique remainsexperimental
and role iscontroversial

63. EMBOLISATION
 Tc99/sulphur colloid labeled contrast
angiogram to detect vascular damage
 Presenceof extravasation of contrast in
arterial phase (blushsign)
 Pseudo aneurysm pattern needstransarterial
embolisation using polyvinyl
alcohol/silicone/acrylic embolicspheres
 Canbe given to reduceblood loss
preoperatively

64. SPLENIC ARTERY EMBOLISATION

65. OPSI
(OVERWHELMING POST SPLENECTOMY
INFECTION)
 Arapidlyfatal infection following removalof
spleen
 Incidence-<1%peryear
 Occurs1stfew yearsaftersplenectomy
 Commonorganisms
• 1.S.Pneumonia
2.H.Influenza
3.N.Meningitis
 Mortality rate-50-80%

66.  Mechanism-organism with polysaccharide
capsulesneedOPSONIZATION with IGg3or
C3Bwhich attaches tospecial macrophages
found in thespleen
 Post splenectomy patients-lack of
macrophages

67. SYMPTOMS
 Starts with flu like symptoms
 Meningitis orsepsis
 Rapidly progressive 12-48hrs

68. OPSI

69. MANAGEMENT
Prevention-
 Pneumococcal Vaccine(>2Yrs) Administered
Within 24 – 48 HrsAfter Splenectomy
 Meningococcal & H.Influenza Vaccine Only In
EndemicAreas
 Antibiotics- PENICILIN V
• 125mg Bd(<3 Yrs),
• 250mgBd(3-14Yrs),
• 500 Mg Bd (Adults)

70. THANKYOU