Blunt trauma abdomen ankit
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Transcript of Blunt trauma abdomen ankit
BLUNT TRAUMA
ABDOMEN
DR ANKIT SHARMA
RESIDENT [SURGERY]
ARMED FORCES MEDICAL COLLEGE
PUNE
Scheme of presentation
Regional anatomy of abdomen
Mechanism of injury
Initial management
Examination
Investigations
Laparotomy
Indications
Approach
Management of specific injuries
Abdominal Compartment Syndrome
2
Regions of abdomen Anterior Abdomen
Superiorly – b/w costal margins
Inferiorly – Inguinal ligament &
pubic symphysis
Laterally – Ant axillary lines
Majority hollow viscera may be
involved
3
Regions of abdomen Thoraco Abdomen
Inferior to
Anteriorly: Trans-nipple line
Posteriorly: Infra-scapular line
Includes
Diaphragm, Liver, Spleen & Stomach
Full expiration diaphragm rises to 4th
ICS Abdo viscera may be injured by
penetrating wounds/ # lower ribs
4
Regions of abdomen Flank
Anteriorly – Ant axillary line
Posteriorly – Post axillary line
Superiorly – 6th ICS
Inferiorly – Iliac crest
Thick musculature – partial barrier
to penetrating wounds
5
Regions of abdomen Back
Posterior to posterior axillary line
From – tip of scapulae
To – Iliac crest
6
Regions of abdomen 7
Regions of abdomen Pelvis
Lower part of retroperitoneal and
intraperitoneal spaces
Rectum, bladder, iliac vessels,
internal reproductive organs
(females)
8
Stats
MVAs responsible for 75% of all blunt abdominal trauma
Multi-organ & multi-system injury
Solid organ injury >> Hollow viscus injury
Spleen (40-55%) > Liver (35-45%) > Small bowel (5-10%)
Retroperitoneal hematoma (15% laparotomies)
9
Mechanism of injury
CRUSHING
Direct application of a blunt force to the abdomen
SHEARING
Sudden decelerations apply a shearing force across organs with
fixed attachments
BURSTING
Raised intraluminal pressure by abdominal compression in hollow
organs can lead to rupture
PENETRATION
Disruption of bony areas by blunt trauma may generate bony
spicules that can cause secondary penetrating injury
10
Injuries from restraint devices 11
Standard initial protocol Spinal stabilization
Maintenance of ABC
IV access (double) and IV fluids
Draw and send blood for investigations, blood grouping
NG tube insertion
Urinary catheterization
12
History
Mode of injury (MVA/ direct blow/ fall from height)
Type of veh & speed
Type of collision (frontal/ lateral/ side/ rear/ rollover)
Response to pre-hospital treatment (by trauma care
personnel)
Explosion – visceral overpressure injuries (more in closed
spaces and less distance of patient from explosion)
13
Physical Examination:
Inspection
Fully unclothe the patient
Whole body thorough inspection
abrasions, contusions from restraint devices, lacerations,
penetrating wounds, impaled foreign bodies, evisceration of
omentum or small bowel, and the pregnant state
Flank, scrotum & perianal area – blood @ meatus, swelling,
bruising, laceration of perineum, vagina, rectum or buttocks
(s/o open pelvic #)
14
The classical
‘seatbelt’ sign.
The bruising on the
left breast is from
the shoulder belt
and the low
bruising to the
abdominal wall is
from the lap belt.
15
Physical Examination:
Palpation & Percussion
Tenderness (Superficial/ deep)
Rebound tenderness
Guarding (Voluntary/ involuntary), rigidity
Dullness/ shifting dullness – intraabdominal
collection
16
Physical Examination:
Auscultation
Difficult in a noisy room
Bowel Sounds +/-
Reliable only when initially present and change later
Absence of bowel sounds – non-specific
17
Pelvic Stability Testing
Pelvic hemorrhage occurs rapidly - Unexplained hypotension
Compression-distraction maneuver
Perform only once; may result in further hemorrhage
Ruptured urethra (high riding prostate, scrotal hematoma, blood @ meatus)
Limb lengthening discrepancy
Rotational leg deformity without e/o fracture
18
Others Vaginal examination
In presence of complex perineal lacerations/ pelvic # or trans-pelvic
GSW
Vaginal laceration may be seen due to pelvic # or penetrating
wounds
Gluteal examination
From iliac crest to gluteal folds
Penetrating injuries – rectal injuries below peritoneal reflection
GSWs & stab wounds – associated with intra-abdominal injuries
19
Others NG tube
Relieve acute gastric dilatation
Decompress stomach before a DPL
Remove gastric contents
Blood in NG Esophageal/ upper GIT injury (after excluding naso/
oro-pharyngeal sources)
Urinary catheter (or SPC)
Relieve retention
Decompress bladder before DPL
Monitor UO as indicator of tissue perfusion
Gross hematuria trauma to genitourinary tract & non renal
intraabdominal organs
20
INVESTIGATIONS –
Aim
To identify To decide When
(those with injury) (which ones (how quickly
need laparotomy) this must be
undertaken)
DIAGNOSTIC STRATEGY
DIAGNOSTIC STRATEGY
cont.. Complete hemogram with hematocrit
ABG, Electrocardiogram
Renal function tests
Urine analysis –
+nce of hematuria – genitourinary injury
-nce of hematuria – does not rule out it
Serum amylase / lipase or liver enzymes - se -suspicion of intraabdominal injuries
Imaging studies
Abdominal X-ray
FAST
DPL
CT Scan
Contrast studies
23
Abdominal X-ray Pneumoperitoneum – hollow viscus perforation
Ground glass appearance – massive haemoperitoneum
Dilated gut loops- retroperitoneal hematoma/ injury
Retroperitoneal air outlining the right kidney – duodenal injury
Double wall sign – air inside and outside the bowel
Distortion or enlargement of outlines of viscera – hematoma in
relation to respective organs
24
Abdominal X-ray Medial displacement of stomach – splenic hematoma
Obliteration of Psoas shadow – retroperitoneal bleeding
Pelvic bone fracture – bladder/urethral/rectal injury
Fracture vertebra – ureter injury / retroperitoneal hematoma
25
Chest X-ray Pneumothorax/haemothorax
Raised left/right hemidiaphragm – perisplenic/hepatic hematoma
Lower ribs fracture – liver/spleen injury
Abdominal contents in the chest – ruptured hemidiaphragm
26
Indications for investigating
further Unexplained hemorrhagic shock
Major chest or pelvic injuries
Abdominal tenderness
Diminished pain response due to
Intoxication
Depressed level of consciousness
Distracting pain
Paralysis
Inability to perform serial examination
27
FAST Focused Assessment Sonography in Trauma
Rapid, accurate, non invasive, inexpensive study
Operator dependant
Views
Pericardial view (Subxiphoid/ parasternal view)
RUQ view - diaphragm-liver interface and Morrison’s pouch
(Sagittal view in MAL in 10th or 11th ICS)
LUQ view - diaphragm-spleen interface and spleen-kidney
interface (Sagittal view in MAL in 8h or 9th ICS)
Suprapubic view (Transverse; before inserting foley’s)
28
FAST Low frequency (3.5 MHz) transducer; allows depth of
penetration necessary to obtain appropriate images
± Second scan 30 min after initial scan - progression
Negative FAST doesn’t rule out intra-abdominal
injury
Difficult in subcutaneous emphysema, obese and
previously operated pts
Absolute indication for a laparotomy =
contraindication for FAST
Pelvic # may decrease the accuracy
29
DPL Diagnostic Peritoneal Lavage
Rapid, invasive, 98% sensitive for intraperitoneal bleed
Indications
Patients with spinal cord injury
Those with multiple injuries and unexplained shock
Obtunded patients with a possible abdominal injury
Intoxicated patients in whom abdominal injury is suspected
Patients with potential intraabdominal injury who will undergo prolonged anesthesia for another procedure
30
DPL Open, semi-open or closed method
Gross blood aspirated – go for Laparotomy
No gross blood – instill 1 lit of warm NS (child –
10ml/kg) – gently agitate the abdomen
Adequate fluid return is > 20% of infused volume
Negative lavage doesn’t exclude retroperitoneal
injuries e.g. pancreatic or duodenal injuries
31
32
DPL Absolute contraindication = obvious need for
laparotomy
Relative contraindications
Pregnancy
Morbid obesity
H/o multiple abdominal surgeries
Positive if
10 ml grossly bloody aspirate before infusing lavage fluid
>100,000/μL RBCs; >500 /μL WBCs; Only 30mL blood
reqd to produce microscopically positive DPL result
↑ amylase, bile, bacteria, vegetable matter or urine +
33
DPL Hemorrhage (false positive results)
secondary to injection of local anesthetic
Incision of the skin or subcutaneous tissues
Peritonitis due to intestinal perforation from the
catheter
Laceration of urinary bladder (if bladder full)
Injury to other abdominal and retroperitoneal
structures requiring operative care
Wound infection at the lavage site (late complication)
34
Abdominal CT Scan Hemodynamically stable patient
Not in emergent need of laparotomy
± Contrast administration (non-ionic contrast)
Organ injury & extent
Retroperitoneal/ pelvic organ injuries
Can miss some GI, diaphragmatic and pancreatic
injuries
Free fluid with no hepatic/ splenic injury suspect GI
or mesenteric trauma
35
DPL Vs FAST Vs CT 36
Contrast studies Urethrography
Cystography
IVP
GI Contrast studies
37
The big question:
Which patients need Laparotomy ?
38
Small answer
Blunt abdominal trauma with hypotension with a
positive FAST or clinical evidence of intraperitoneal
bleeding
Blunt or penetrating abdominal trauma with a positive
DPL
Hypotension with a penetrating abdominal wound
Gunshot wounds traversing the peritoneal cavity or
visceral/vascular retroperitoneum
39
Small answer
Bleeding from the stomach, rectum, or genitourinary
tract from penetrating trauma
Peritonitis
Free air, retroperitoneal air, or rupture of the
hemidiaphragm
CECT findings of ruptured GIT, intraperitoneal bladder
injury, renal pedicle injury, or severe visceral
parenchymal injury after blunt or penetrating trauma
40
LAPAROTOMY Generous midline incision
Transverse incision in children < 6 yrs
Scalpel better than cautery.
Forget the bleeding from incision till definite source of bleed
found
Remove blood and blood clots with abdominal swabs
Palpate spleen and liver first and pack if fractured
Source localized direct digital occlusion (vascular injury)
or pad packing (solid organ injury)
Liver bleed – hepatic pedicle clamping with vascular clamp
(Pringle maneuver)
41
Liver bleed control 42
LAPAROTOMY Splenic bleed – clamp splenic hilum (better than packing
alone)
Rotate spleen medially
Incise lateral peritoneum & endoabdominal fascia
Spleen and pancreas can be dissected from retroperitoneum
as a composite , ant to Gerota’s fascia
43
Splenic mobilization 44
MANAGEMENT OF
SPECIFIC INJURIES
45
Liver trauma 46
Liver trauma 47
Primary aim is to arrest bleeding
Perihepatic packing is effective most of the times, if
not then perform Pringle maneuver
Difficult to perform perihepatic packing in Lt lobe
Mobilize it and compress between surgeon’s hands
Pringle maneuver
Bleeding stopped => from AHA / PV
Doesn’t stop => HVs and retrohepatic IVC is the source Packing Failed direct vascular repair ± hepatic vascular
isolation
Repair the Hepatic artery proper
Cholecystectomy if Rt hepatic artery is ligated
Liver trauma 48
Minor lacerations
Manual compression
Topical hemostats (cautery, argon beam coagulator,
gelfoam, fibrin glue, collagen)
Shallow lacerations running suture
Deep lacerations
Interrupted Hz mattress parallel to edge of laceration
Omentum to fill large defects (obliterates dead space;
source of macrophages)
Deep recalcitrant hemorrhage hepatic lobar arterial
ligation
Liver trauma 49
Repeat laparotomy within 24 hrs for pack removal
Ongoing hemorrhage – early exploration (<24h h)
Complex injuries – angioembolization
Complex injuries – typical ‘liver fever’ upto 5 days post
injury
Non-anatomical resection – stable without coagulopathy
GB injury cholecystectomy
EHBD Transaction Roux-en-Y choledochojejunostomy
Till then intubate the duct for external drainage
Complications – hemorrhage, hepatic necrosis, bilomas,
arterial pseudoaneurysms and biliary fistulas
Liver trauma - NOM 50
Basis
50-80% of liver bleed stops spontaneously
Better results of NOM in children
Significant development of CT scan in liver imaging
Initially introduced for minor injuries (1972)
Presently being used for grades III – V also
Selection criteria
Hemodynamic stability after initial resuscitation
No other visceral/ retroperitoneal injuries needing surg
Multidisciplinary team – Experienced surgeon,
Intensivist, CT scan, 24x7 OT facilities
Liver trauma - NOM 51
Failure rate significantly higher in Gd IV & V than Gd I-
III
Most common reason for intervention – co-existing
abdo injury (e.g. bleed form spleen or kidney)
Predictors of NOM failure
Advanced age
Anaemia & HTN
Active extravasation on CT
Massive blood transfusion
CT follow up for Gd I & II not necessary
Others need clinical and CT follow up
Splenic trauma 52
Splenic trauma 53
Management options
Observation
Angiographic Embolization (Gd I-III; age < 55y)
Surgery (Splenectomy/ partial splenectomy/ splenorrhaphy)
Depending upon
Hemodynamic status of pt
Grade of injury
Presence of other injuries
Medical co-morbidities
Upto 20% patients require early splenectomy
Delayed hemorrhage/ rupture can occur weeks after injury
Splenic trauma 54
Splenectomy (with auto-transplantation)
Hilar injuries
Pulverized splenic parenchyma
GD III and above + coagulopathy/ multiple injuries
Partial splenectomy – isolated polar injuries
Splenorrhaphy – cautery, argon beam coagulator,
gelfoam, fibrin glue, collagen, envelopment in absorbable
mesh, pledgeted suture repair
Bleeding edges – Hz mattress sutures + parenchymal
compression
Splenic Auto-transplantation 55
Splenic Bleeding Edges 56
Splenic trauma 57
Post splenectomy hemorrhage
Loosening of tie around splenic vessels
Improperly ligated/ missed short gastric artery
Recurrent splenic bleed
Post-op complications
Subphrenic abscess (pigtail drainage)
Pancreatic tail injury (Iatrogenic)
Gastric perforation (during short gastric ligation)
OPSI
Splenic trauma - NOM 58
Basis
Salvaging functional splenic tissue – avoids surgical &
anesthetic complications
No risk of post-splenectomy abscess
Indications
Hemodynamically stable patients (Gd I - III)
No other intra-abdominal injuries needing laparotomy
Active contrast extravasation/ blush on CT
> 70 % patients still undergo splenectomy after NOM
Higher failure rates of NOM with increasing grades of
severity
Splenic trauma – NOM 59
Absolute bed rest & NPO
6 hrly Hb check in first 24h
Allowed orally if Hb stable & no surg intervention likely
Follow-up CT: Falling Hb, abdo pain, fever, Lt shoulder
pain
Duration based on
Gd of splenic injury
Nature & severity of other injuries
Clinical Status (Incl peritoneal signs – missed hollow viscus
injury & Hb levels)
Embolization – 73-97% success rate
Stomach & Small Intestine 60
Gastric Wounds – running single layer suture (full
thickness bites)/ stapler
Partial gastrectomy – for destructive injuries
Small intestine injury < 1/3rd of bowel circumference
transverse running 3-0 PDS
Multiple injuries/ mesenteric injuries – segmental
resection and anastomosis/ stoma
Post-op ileus is obligatory
No enteral feeds for atleast 48 hrs
TEN to be started at 20mL/h once resuscitation is
complete
Duodenum 61
Duodenal hematoma – NG aspiration & parenteral
nutrition
Small duodenal perforation/ laceration – primary single
layer repair
1st part injuries – debridement & end-to end anastomosis
with gastric antrum/ pylorus
2nd part injuries – patch with vascularized jejunal graft
3rd & 4th part injuries – resection and anastomosis on Lt
side of Superior mesenteric vessels
Pyloric exclusion – high risk, complex duodenal repairs
Pancreas 62
Management depends on location of injury to
Parenchyma
Intrapancreatic CBD
MPD
Contusion (ductal system intact)/ proximal pancreatic
injuries (to Rt of SM vessels)
Non operative/ closed suction drain
Distal duct disruption (body & tail) – distal
pancreatectomy with splenic preservation
Injury to Head with duct injury – distal duct ligation with
Roux-en-Y choledochojejunostomy
Colon & Rectum 63
3 methods for colonic injuries
Primary repair
End colostomy
Primary repair with diverting colostomy
Weigh the risk of primary repair Vs colostomy
Lt colon injuries - Temporary colostomy
Other high risk pts - Diverting ileostomy with colocolostomy
Rectal injuries – loop ileostomy/ sigmoid loop colostomy
Accessible rectal injury – attempt primary repair with diversion
Extensive rectal injury – End colostomy (Hartmann’s)
Complications: Intra-abdo abscess, fecal fistula, infection,
stomal complications
Genitourinary Tract 64
90 % Renal injuries managed conservatively
Hematuria resolves in few days with absolute rest
Operative intervention – Hypotension due to
Renovascular injuries
Destructive parenchymal injuries
Persistent gross hematuria – embolization
Urinoma – Percutaneous drainage
Renal artery repair
Success rates very low
Image guided endostent placement can be attempted
Genitourinary Tract 65
Renorrhaphy
Take vascular control for proper visualization
Preserve renal capsule
Collecting system is closed separately with absorbable
sutures
Preserved capsule is closed over collecting system repair
Ureter injuries
Primary repair with renal mobilization for tension relief
Reimplantation (with psoas hitch) for distal ureter injuries
Damage control – B/L ligation + Nephrostomy
Renorrhaphy 66
Genitourinary Tract 67
Bladder injuries
Intraperitoneal injuries
Running, single layer 3-0 absorbable monofilament suture
Lap repair – if other injuries not needing repair
Extraperitoneal injuries
NOM with bladder decompression for 2 wks
Urethral injuries
Bridge the defect with Foley’s
Elective repair for strictures later
Vascular Injuries 68
ABDOMINAL COMPARTMENT SYNDROME
Symptomatic organ dysfunction that results from increased intraabdominal pressure (IAP)
Increased IAP is an under-recognized source of morbidity and mortality.
1-day point-prevalence observational trial conducted in 13 medical ICUs of six countries with 97 patients, 8% had IAP > 20mmHg.
The incidence of ACS in trauma patients is estimated to be between 2 and 9 percent.
ABDOMINAL COMPARTMENT SYNDROME
Massive volume resuscitation in the leading cause of ACS.
Inflammatory states with capillary leak, fluid sequestration, inadequate tissue perfusion, and lactic acidosis can develop ACS.
Gastric overdistention following endoscopy has resulted in ACS.
ETIOLOGY
ABDOMINAL COMPARTMENT SYNDROME
The IAP is usually 0 mmHg during spontaneous respiration
Slightly positive in the patient on mechanical ventilation
IAP increases in direct relation to body mass index.
Supine hospitalized patients had a mean baseline value of 6.5
mmHg.
The compliance of the abdominal wall limits the rise in IAP but
increases rapidly after a critical IAP
Critical IAP varies from patient to patient, based on abdominal
wall compliance on perfusion gradient
IAH often defined as IAP > 12mmHg
Previous pregnancy, cirrhosis, morbid obesity, may increase
abdominal wall compliance and can be protective
PATHOPHYSIOLOG
Y
ABDOMINAL COMPARTMENT SYNDROME
CLINICAL MANIFESTATIONS
CENTRAL NERVOUS SYSTEM
Intracranial pressure
Cerebral perfusion pressure
CARDIAC
Hypovolemia
Cardiac output
Venous return
PCWP and CVP
SVR
PULMONARY
Intrathoracic pressure
Airway pressures
Compliance
PaO2 PaCO2
Shunt fraction
Vd/Vt
GASTROINTESTINAL
Celiac blood flow
SMA blood flow
Mucosal blood flow
pHi
RENAL
Urinary output
Renal blood flow
GFR
HEPATIC
Portal blood flow
Mitochondrial function
Lactate clearance
ABDOMINAL WALL
Compliance
Rectus sheath blood flow
ABDOMINAL COMPARTMENT SYNDROME
50 mL of sterile saline is instilled into the bladder via the aspiration port of the Foley catheter with the drainage tube clamped.
An 18-gauge needle attached to a pressure transducer is then inserted in the aspiration port, and the pressure is measured. The transducer should be zeroed at the level of the pubic symphysis.
ABDOMINAL COMPARTMENT SYNDROME
MANAGEMENT
GRADING OF ABDOMINAL COMPARTMENT SYNDROME
GradePressure
(mmHg)Management
I 10-15 Maintenance of normovolemia
II 16-25 Volume administration
III 26-35 Decompression
IV >35 Re-exploration
Abdominal Perfusion Pressure (APP): APP = MAP - IAP
In one retrospective study, the inability to maintain an APP
above 50 mmHg predicted mortality with greater sensitivity
and specificity than either IAP or MAP alone .
ABDOMINAL COMPARTMENT SYNDROME
OPERATIVE DECOMPRESSION
Vacuum-assisted
temporary abdominal
closure device:
Thin plastic sheet, a
sterile towel, closed
suction drains, and a
large adherent
operative drape. This
dressing system
permits increases in
intra-abdominal
volume, without a
dramatic elevation in
IAP.
ABDOMINAL COMPARTMENT SYNDROME
ACS is a clinical entity caused by an acute, progressive increase in IAP.
Multiple organ systems are affected, usually in a graded fashion.
The gut is the organ most sensitive to IAH.
Treatment involves expedient decompression of the abdomen.
Pt already physiologically compromised Keep high degree of suspicion and a low threshold for checking bladder pressures to prevent the associated mortality
SUMMARY
References
ATLS Manual 9th Ed
Schwartz Principles of Surgery, 10th Ed
Sabiston Textbook of Surgery, 20th Ed
Manual of Trauma Surgery, Dept of
Surgery, AFMC, 2013
Trauma, Moore, 6th Ed
77