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Management of abdominal trauma

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Management of abdominal trauma

  1. 1. Management Of Abdominal Trauma BY : CHONG LIH YIN
  2. 2. Index 1. classification of abdominal injury 2. Pathophysiology of abdominal injury -PAT, BAT 3. Primary Survery 4. Secondary Survey- Physical examination,Lab Test 5. Imaging –Plain radiography , FAST scan, CT 6. Other diagnosis method -DPL,LWE,,Laparascopy, Exploratory Laparatomy 7. Management of BAT and PAT 8. Specific Organ injury 9. -Spleen , Diaphragm, stomach , small intestine, Colorectal injury, 10. Damage control resuscitation 11. Abdominal compartment syndrome 12. Reference
  3. 3. Abdominal Trauma Blunt Abdominal Trauma ◦ Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/systems) ◦ Most commonly injured organs? - spleen > liver, intestine is the most likely hollow viscus. ◦ Most common causes? - MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%) Penetrating Abdominal Trauma ◦ Stabbing 3x more common than firearm wounds ◦ Gun shot wound cause 90% of the deaths ◦ Most commonly injured organs? - small intestine > colon > liver
  4. 4. Pathophysiology of injury Penetrating Abdominal Trauma Stab Wounds ◦ Knives, ice picks, pens, coat hangers, broken bottles ◦ Liver, small bowel, spleen Gunshot wounds ◦ small bowel, colon and liver ◦ Often multiple organ injuries, bowel perforations Rosen’s Emergency Medicine, 7th ed. 2009
  5. 5. Pathophysiology of injury Rosen’s Emergency Medicine, 7th ed. 2009
  6. 6. Pathophysiology of injury Blunt Abdominal Trauma • Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures • Crushing effect • Acceleration and deceleration forces → shear injury • Seat belt injuries ◦ “seat belt sign” = highly correlated with intraperitoneal injury Rosen’s Emergency Medicine, 7th ed. 2009
  7. 7. Primary Survey –ATLS approach ABCDE pattern: Airway, Breathing, Circulation, Disability (neurologic status), and Exposure. A -intubation may be required if patient is shocked, hypotensive or unconscious or in need for ventilation. *with cervical precaution. B -watch for hemothorax in both blunt and penetrating thoracoabdominal injuries. C -start with 2 L crystalloid (If active bleeding you must find source and stop the bleeding) D –May seen associated with thorocolumbar # E -Watch for other injury
  8. 8. Diagnostic and treatment priorities First : recognize presence of shock or intraabdominal bleeding Recognize Second : start resuscitative measures for shock/bleeding Resuscitation Third : determine if abdomen is source for shock or bleeding Abdomen? Fourth: determine if emergency laparatomy is needed Laparatomy ? Fifth: complete secondary survery,ab,and radiograph studies to determine if “occult” abdominal injury is present. Survey Sixth : conduct frequent reassessments.Reassessment
  9. 9. Secondary Survey History History for all trauma patients: -Not necessary making an accurate diagnosis S.A.M.P.L.E S: Symptoms: pain,vomiting,hematuria,hematochezia,dyspnea,respiratory distress… A: Allergies M : Medications L : Last meals E : Events (mechanism of injury)
  10. 10. Physical Examination Inspection : abrasions, contusion, lacerations, deformity, entrance and exit wounds to determine path of injury… (grey Turner, Kehr, Balance,Cullen,seat belt sign) Palpation: elicits superficial , deep , or rebound tenderness; involuntary muscle duarding Percussion : subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum. Auscultation : bowel sounds may be decrease ( late finding).
  11. 11. Physical examination Grey-Turner sign : bluid discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancrease,kidney or pelvic fracture. Cullen sign : bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage. Kehr sign: shoulder pain while supine ;caused by diaphragmatic irritation(splenic injury, free air, intra-abdominal bleeding) Balance sign : dull percussion in LUQ.Sign of splenic injury; blood accumulation in subcapsular or extracapsular spleen In the trauma patient, a ‘normal’ physical exam of the abdomen doesn’t equate to much. You NEED to do further testing.
  12. 12. Laboratory tests - limited -Hematocrit – below 30% increases the likelihood of intra- abdominal injury. -Leukocyte count – In BAT, the white blood cell (WBC) count is nonspecific and of little value. Catecholamine release due to trauma can cause demargination and may elevate the WBC to 12,000 to 20,000/mm3 with a moderate left shift. Solid or hollow viscus injury can cause comparable elevations -Pancreatic enzymes – Normal serum amylase and lipase concentrations cannot exclude significant pancreatic injury . And while elevated concentrations raise the possibility of pancreatic injury, -Liver function tests – Hepatic injury is associated with elevations in liver transaminase concentrations -Urinalysis – Gross hematuria suggests serious renal injury and mandates further investigation -Base deficit and lactate - Base deficit less than -6 was associated with intra-abdominal hemorrhage and the need for laparotomy and blood transfusion
  13. 13. / Imaging in Abdominal Trauma Plain films generally have NO ROLE in acute abdominal trauma What else do we have? • FAST ultrasound • Diagnostic Peritoneal Tap • CT Scan, contrast study • Local wound exploration • Angiography • Urethrocystography • IVU
  14. 14. Plain radiograph Findings on chest radiograph that suggest intra- abdominal injury include: Lower rib fracture •Diaphragmatic hernia •Free air under the diaphragm
  15. 15. (FAST) Focused assessment with sonography for trauma - To diagnosed free intraperitoneal fluid. - evaluate solid organ hematoma - Four areas: 1. Pericardium (subxiphoid) 2. Perihepatic &hepatorenal space (morrison’s pouch) 3. Perisplenic 4. Pelvis (pouch of Douglas /rectovesical pouch) Sensitivity 60-95% for detecting 100ml -500 ml of fluid E-fast(extended) -add thoracic windows to look for pneumothorax. Sensitivity 59%,specificity,specificity up to (99% for pneumothorax. ) 12 3 4
  16. 16. FAST Ultrasound Advantages • Sensitivity at detecting 100cc fluid is 60- 95% • Portable(bedside),fast(<5 min) and ability to repeat • No radiation or contrast • Noninvasive • Rapid results, hemodynamically unstable patient that unable to go for CT scan • Less expensive Disadvantages • -Injury to solid parenchyma, the retroperitoneum, or the diaphragm is not well seen. • -Uncooperative patients, obesity, bowel gas, and subcutaneous air interfere with image quality. • -Low sensitivity in comparison to CT, particularly for non-hypotensive patients. Cannot reliably exclude clinically significant injuries • -Blood cannot be distinguished from ascites or urine. • -Subcapsular injuries cannot be detected. • -Insensitive for detecting bowel injury • -Limited in detecting<200cc intraperitoneal fluid
  17. 17. Pericardium (subxiphoid)
  18. 18. FAST-Morrison’s pouch (hepato-renal space) Rosen’s Emergency Medicine, 7th ed. 2009
  19. 19. FAST Perisplenic view
  20. 20. FAST-Retrovesicle (Pouch of Douglas) trauma.orgRosen’s Emergency Medicine, 7th ed. 2009
  21. 21. CT Imaging ◦ Accurate for solid visceral lesions and intraperitoneal hemorrhage ◦ guide nonoperative management of solid organ damage ◦ IV not oral contrast ◦ Disadvantages : insensitive for injury of the pancreas, diaphragm, small bowel, and mesentery Rosen’s Emergency Medicine, 7th ed. 2009
  22. 22. Diagnostic Peritoneal Taps DPA - The recovery of 10 cc of frank blood (or more) from the peritoneum is a strong predictor (90% PPV in blunt trauma) of intraperitoneal injury, and the procedure is then terminated. DPL - If aspiration findings are negative, lavage is conducted in which the peritoneal cavity is washed with saline. RBC count exceeding 100,000/cc is considered positive and generally specific for injury. Sensitivity 90%.
  23. 23. Diagnositic Peritoneal ‘Lavage’ Is actually a 2 Step Process. Step 1. DPA (closed). ◦ Patient supine ◦ Landmark is 2 finger widths below umbilicus ◦ Local freezing, puncture skin 30-degrees to the head ◦ Seldinger technique to introduce a DPL catheter ◦ Aspirate using 30cc syringe
  24. 24. DPA Advantages ◦ Highly accurate for hemoperitoneum (SENS 90-100%) ◦ Most sensitive test for hollow viscus injury Disadvantages ◦ Invasive (complication rate 1-5%) ◦ Time consuming (20 minutes) ◦ False positives. Up to 25% non-therapeutic laparotomies
  25. 25. DPA •If 10cc frank blood or more is aspirated, you are done, patient needs to go to the OR. If the DPA is negative, you proceed to Step 2…
  26. 26. Diagnostic Peritoneal Lavage Step 2. DPL. ◦Hook up 1L of Ringer’s to the peritoneal catheter, and squeeze into the abdomen. ◦Once infused, put the empty Ringer’s bag on the floor, and let it back-fill via gravity ◦Send off 10cc for analysis, if 100,000 RBC/cc it is positive
  27. 27. Is there still a role for DPA? FAST has largely replaced DPA, likely due to ease of use. However, 2 areas where still is warranted: ◦ Hemodynamically unstable and an equivocal FAST ◦ No FAST available “DPL is safe, sensitive, and reduces the use of CT” (Journal of Trauma 2007)
  28. 28. Local Wound Exploration To determine the depth of penetration in stab wounds  If peritoneum is violated, must do more diagnostics Prep, extend wound, carefully examine (No blind probing) Indicated for anterior abdominal stab wounds, less clear for other areas Rosen’s Emergency Medicine, 7th ed. 2009
  29. 29. Laparoscopy Most useful to eval penetrating wounds to thoracoabdominal region in stable pt esp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscope diaphragm, solid viscera, stomach, small bowel. Disadvantages: poor sensitivity for hollow visceral injury, retroperitoneum Complications from trocar misplacement. If diaphragm injury, PTX during insufflation
  30. 30. Exploratory laparatomy Potential indications include the following: Haemodynamic instability  Evidence of Peritonitis to achieve control of haemorrhage and control of spillage Traumatic diaphragmatic injury with herniation  Severe solid organ injury (e.g. kidney and spleen)  Infarction due to post traumatic occlusion of the blood supply  Mesenteric tear/s  Unexplained Moderate to large amounts of free fluid (200-≥500mls)  Failed non-operative management
  31. 31. Management of BAT • NOM: nonoperative management • Abd CT: abdominal CT scan; • DPT: diagnostic peritoneal tap; • LAP: laparotomy
  32. 32. Management of penetrating abdominal trauma Mandatory laparotomy vs Selective nonoperative management
  33. 33. Management of penetrating abdominal trauma Mandatory laparotomy ◦ standard of care for abdominal stab wounds until 1960s, for GSWs until recently ◦ Now thought unnecessary in 70% of abdominal stab wounds ◦ Increased complication rates, length of stay, costs ◦ Immediate laparotomy indicated for shock, evisceration, and peritonitis
  34. 34. Management of penetrating abdominal trauma Selective management used to reduce unnecessary laparotomies Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair Strategy depends on abdominal region: Thoracoabdomen Nipple line to costal margin Anterior abdomen Xiphoid to pubis Flank and back Posterior to anterior axillary line
  35. 35. Management of penetrating abdominal trauma Thoracoabdomen Big concern is diaphragmatic injury ◦ 7% of thoracoabdominal wounds Diagnostic evaluation: ◦ CXR (hemothorax or pneumothorax) ◦ Diagnostic peritoneal lavage ◦ FAST ◦ Thoracoscopy Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
  36. 36. Thoracoabdomen
  37. 37. Management of penetrating abdominal trauma Anterior abdomen ◦ Only 50-70% of anterior stab wounds enter the abdomen ◦ of these, only 50-70% cause injury requiring OR 1. is immediate lap indicated ? 2. Has peritoneal cavity been violated? 3. Is laparotomy required?
  38. 38. Management of penetrating abdominal trauma Back/Flank ◦ Risk of retroperitoneal injury ◦ Intraperitoneal organ injury 15- 40% ◦ Difficulty evaluating retroperitoneal organs with exam and FAST ◦ In stable pts, CT scan is reliable for excluding significant injury: Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
  39. 39. Management of PAT Anterior abdomen laparoscopy (LPY), or serial physical examinations (SPEs)
  40. 40. Management of penetrating abdominal trauma Gunshot wounds Much higher mortality than stab wounds Over 90% of pts with peritoneal penetration have injury requiring operative management Most centers proceed to lap if peritoneal entry is suspected Expectant management rarely done
  41. 41. Management of PAT Gunshot wounds -assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited) laparoscopy (LPY), or serial physical examinations (SPEs)
  42. 42. Specific Organ Injury Specific organ trauma: 1. peritoneal 2. retroperitoneal 3. diaphragm -Treatment of an organ injury is similar whether the injury mechanism is penetrating or blunt -An exception to the rule is a retroperitoneal hematoma -explore all retroperitoneal hematoma caused by penetrating injury.
  43. 43. Splenic Injury - Grading System(AAST) I - Hematoma, subcapsular <10% SA Capsular Laceration <1cm II - Hematoma, subcapsular 10-50% SA; intraparenchymal <5cm Capsular Laceration 1-3cm III - Hematoma, subcapsular >50% SA; intraparenchymal >5cm Capsular Laceration >3cm (or parenchymal depth) IV - Hematoma ruptured into parenchyma Hilar Injury devascularizing spleen >25% V - Vascular hilar injury devascularing spleen 100%, or ‘Shattered’
  44. 44. WSES classification Minor spleen injuries: WSES class I includes hemodynamically stable AAST-OIS grade I–II blunt and penetrating lesions. Moderate spleen injuries: WSES class II includes hemodynamically stable AAST-OIS grade III blunt and penetrating lesions. WSES class III includes hemodynamically stable AAST-OIS grade IV–V blunt and penetrating lesions. Severe spleen injuries: WSES class IV includes hemodynamically unstable AAST-OIS grade I–V blunt and penetrating lesions.
  45. 45. Diaphragmatic injury Its possible in injuries to the thoracoabdominal region Can be due to blunt(>85%) or penetrating injury and is larger in the blunt Possible cardiac injury if the penetrating wound is more central The weakest point of diaphragm is the left posteriorlateral(80%) Often missed in multitrauma In isolated injury it may go unnoticed and there is often a delay between the injury and the diagnosis Patients present with non specific symptoms and may complain of chest pain,abdominal pain,dyspnea ,tachypnea and cough Rupture with herniation is diagnosed by CXR or CT but without herniation is difficult to diagnose Thoracoscopy or laparascopy is diagnostic
  46. 46. Treatment Once identified must be repaired because it will not close spontaneously regardless the size. Early diagnosis needs abdominal approach using the interrupted nonabsorbable suture and the large defect(>25cm2) may need nonabsorbable mesh. In the event of a gross contamination, endogenous tissue can be utilized for a definitive repair as latissimus dorsi flap, tensor fascia lata or omentum. There are some who advocate using biologic tissue grafts, such as AlloDerm(human acellular tissue matrix).The durability of such a repair is questionable. Place chest tube on the surgery side at the time of repair
  47. 47. Stomach More common in penetrating trauma than blunt & its about 10% of penetrating injuries of the abdomen Diagnosis: Physical exam: -epigastric tenderness, -peritoneal signs, -bloody gastric aspirate. Plain radiography in <50%: -free air under diaphragm • FAST examination:- unreliable • DPL: WBC, RBC < Gross contamination • CT scan: pneumoperitoneum • Laparoscopy:-operator dependent
  48. 48. Stomach treatment is according to the severity administer preop abx Hematoma is evacuated ,hemostasis and closure with nonabsorbable suture. Small perforation can be closed in one or two layered Large injuries near the greater curvature can be closed by suture or GIA stapler Certain defects may be closed using a TA stapler A pyloric wound may be converted to pyloroplasty Destructive wound may need proximal or distal gastrectomy In rare cases a total gastrectomy and Roux-en –y esophagojejunostomy are necessary for severe cases.
  49. 49. Small intestine The small bowel is the mc injured intraabdominal organ in penetrating tauma, a blunt trauma cause is less common,but not rare(10%) Small isolated perforation probably result from blowout of pseudoclosed loops(seatbelt related injuries) Larger perforation, complete disruptions and injuries associated with large mesenteric hematoma or laceration are caused by direct blows or shearing injury or contusion Perforation from blunt injury is the mc at the ligament of triez,ileocecal valve,midjejunum or in the areas of adhesion
  50. 50. Small intestinee • CT has a significant false negative rate in the diagnosis of small- bowel injury. • CT findings in small-bowel injury include: Fluid collections without solid viscus injury Bowel wall thickening  Mesenteric infiltration Free intraperitoneal air  Oral contrast extravasation
  51. 51. Colon and rectum -Diagnosis • Peritoneal signs or free intraperitoneal air. • At laparotomy, small injuries in the wall of the colon can be missed so explore all blood staining or hematomas of the colonic wall. • Consider proctoscopy or proctosigmoidescopy in : - Gross blood on PR in the presence of a pelvic fracture - Penetrating abdominal, buttock, thigh or pelvic wound. - Any patient with a major pelvic fracture if the patient is stable. • The location of the injury can be important in planning the operation. Even if the hole cannot be visualized on proctoscopy, assume the patient has a colorectal injury, if there is intraluminal blood. • In hemodynamically unstable patients, proceed with laparotomy first.
  52. 52. Colon and rectum Current operative options include : -Primary repair of the injury, -.Resection and anastomosis, and -Colostomy..
  53. 53. Traditional contraindications to primary repair include : • Patients with shock, underlying disease, significant associated injuries, or peritonitis • Extensive intraperitoneal spillage of feces, • Multisegmental or extensive colonic injury requiring resection, and • Major loss of the abdominal wall or mesh repair of the abdominal wall; Colon and rectum Treatment is operative If a primary repair cannot be performed safely for anatomic reasons (bowel wall edema, vascular compromise), a colostomy may be a safer option. The guidelines for primary repair include : • Minimal fecal spillage, • No shock (defined as systolic blood pressure <90 mmHg), • Minimal associated intraabdominal injuries, • <8-hour delay in diagnosis and treatment, and • <1-L blood transfusion. Colon and rectum
  54. 54. Rectum -intraperitoneal or extraperitoneal 1.Often, intraperitoneal rectal injuries can be managed as in colonic injury (primarily repaired). 2.Treat extraperitoneal rectal tears by diverting sigmoid colostomy. Acceptable options include: • Hartmann resection with end colostomy, • End colostomy with a mucus fistula, or • Loop colostomy with a stapled distal end. 3.If the defect is not readily identified on proctoscopy….. 4.Presacral drainage and irrigation of the distal rectal stump….. 5.If a colostomy is necessary in a patient with a pelvic fracture requiring fixation…… 6.Perioperative broad-spectrum antibiotics should be administered for colon and rectal wounds
  55. 55. Damage control Resuscitation It’s an alternative resuscitation approach to hemmorhagic shock which involves: 1. rapid control of surgical bleeding 2. Early and increased use of RBC, 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). -can be applied to unstable patient who are with life threatening hemorrhage & going to need massive transfusion.
  56. 56. Indication of damage control resuscitation
  57. 57. Approach Before: ER->OR ->death Now: ER->OR->DCS->ICU->OR->ICU
  58. 58. Major complication of abdominal trauma- Abdominal Compartment Syndrome Common problem with abdominal trauma Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure ◦ ± APP below 50 mm Hg Primary ACS: associated with injury/disease in abdomen Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak) Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
  59. 59. Abdominal Compartment Syndrome Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29
  60. 60. Abdominal Compartment Syndrome Effects of elevated IAP ◦Renal dysfunction ◦Decreased cardiac output ◦Increased airway pressures and decreased compliance ◦Visceral hypoperfusion Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
  61. 61. Abdominal Compartment Syndrome Management ◦ Surgical abdominal decompression ◦ Nonsurgical: paracentesis, NGT, sedation ◦ Staged approach to abdominal repair ◦ Temporary abdominal closure
  62. 62. Conclusions Watch out for implements and missiles violating the abdomen Laparotomy is mandatory if shock, evisceration, or peritonitis Diagnostic studies used to determine need for laparotomy in PAT and BAT FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal blood Damage Control is a principle of staged operative management with control and resuscitation prior to definitive repair Abdominal compartment syndrome is a common problem in abdominal trauma
  63. 63. Reference Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617 https://wjes.biomedcentral.com/articles/10.1186/s13017-017-0151-4# http://www.aast.org/library/traumatools/injuryscoringscales.aspx#pancreas https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-abdominal-trauma- in- adults?search=abdominal%20trauma&source=search_result&selectedTitle=1~150&usage_type=d efault&display_rank=1#subscribeMessage