Blunt trauma abdomen

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(OPERATIVE v/s CONSERVATIVE MANAGEMENT)
Dr.Anil Haripriya

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Blunt trauma abdomen

  1. 1. <ul><li>BLUNT TRAUMA ABDOMEN </li></ul><ul><li>(OPERATIVE v/s CONSERVATIVE MANAGEMENT) </li></ul><ul><li>Dr.Anil Haripriya </li></ul>
  2. 2. INTRODUCTION <ul><li>Motor vehicle accidents are responsible for 75% of all blunt trauma abdominal injuries </li></ul><ul><li>More common in elderly due to less resilience. </li></ul><ul><li>Blunt injuries causes solid organ trauma (spleen, liver and kidneys) more often than hollow viscera. </li></ul><ul><li>Multi organ injury and multiple system injury are also more common in blunt injury than in other types. </li></ul>
  3. 3. MECHANISMS OF INJURY <ul><li>CRUSHING </li></ul><ul><li>Direct application of a blunt force to the abdomen </li></ul><ul><li>SHEARING </li></ul><ul><li>Sudden decelerations apply a shearing force across organs with fixed attachments </li></ul><ul><li>BURSTING </li></ul><ul><li>Raised intraluminal pressure by abdominal compression accurately in hollow organs can lead to rupture </li></ul><ul><li>PENETRATION </li></ul><ul><li>Disruption of bony areas by blunt trauma may generate bony spicules that can cause secondary penetrating injury </li></ul>
  4. 4. <ul><li>PRESENTATION </li></ul><ul><li>Varies widely from haemodynamic stability with minimal abdominal signs to complete cardiovascular collapse and may change from one to the other with alarming rapidity </li></ul>
  5. 5. INITIAL ASSESSMENT <ul><li>Whether the patient is haemodynamically </li></ul><ul><li>stable unstable </li></ul><ul><li>FIRST PRIORITIES PROTOCOL : </li></ul><ul><li>Brief clinical examination to evaluate ABC along with cardiovascular status with blood pressure and pulse measurement . </li></ul><ul><li>Accordingly, resuscitation and management of shock by </li></ul><ul><ul><ul><ul><ul><li>maintenance of ABC </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>IV fluids </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>nasogastric tube insertion </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Catheterization </li></ul></ul></ul></ul></ul>
  6. 6. <ul><li>SECOND PRIORITIES PROTOCOL </li></ul><ul><li>Physical examination </li></ul><ul><li>Base line investigations </li></ul><ul><li>Four quadrant tap </li></ul><ul><li>Diagnostic peritoneal lavage (DPL) </li></ul><ul><li>Ultrasound – FAST (focus assessment with sonography for trauma) </li></ul><ul><li>Abdominal CT scan </li></ul><ul><li>Diagnostic laparoscopy </li></ul><ul><li>Laparotomy </li></ul>
  7. 7. HISTORY AND PHYSICAL EXAMINATION <ul><li>HISTORY : </li></ul><ul><li>To know injury mechanism (mode of injury) – </li></ul><ul><li>to anticipate injury patterns and raise the index of suspicion for occult injury </li></ul><ul><li>Events preceding the injury </li></ul><ul><li>General principles : - Serial examinations by the same examiner improves sensitivity </li></ul><ul><li>- Spinal cord injury masks clinical findings </li></ul><ul><li>- Tenderness blunted by intoxicants </li></ul>
  8. 8. PHYSICAL EXAMINATION <ul><li>General Examination : relating to hemodynamic stability </li></ul><ul><li>Abdominal findings : </li></ul><ul><li>Inspection : </li></ul><ul><li>for abdominal distension </li></ul><ul><li>for contusions or abrasions </li></ul><ul><li>lap belt ecchymosis – mesenteric, bowel, and lumbar spine injuries </li></ul><ul><li>periumblical (Cullen sign) and flank (Grey Turner Sign) ecchymosis – retroperitoneal haematoma </li></ul>
  9. 9. <ul><li>- Palpation : </li></ul><ul><li>for tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum </li></ul><ul><li>Percussion : </li></ul><ul><li>Dullness/ shifting dullness – intrabdominal collection </li></ul><ul><li>Auscultation : </li></ul><ul><li>+/- nce of bowel sounds </li></ul>PHYSICAL EXAMINATION cont.
  10. 10. 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 lapbelt.
  11. 11. <ul><li>Rectal findings </li></ul><ul><li>Check for gross blood - pelvic fracture </li></ul><ul><li>Determine prostate position – high riding prostate – urethral injury </li></ul><ul><li>Assess sphincter tone – neurologic status </li></ul><ul><li>Distal pulses </li></ul><ul><li>Assess for absence or asymmetry </li></ul><ul><li>Assessment of other associated injuries i.e. multiple fractures, spinal injuries etc. </li></ul>PHYSICAL EXAMINATION cont..
  12. 12. DIAGNOSTIC STRATEGY INVESTIGATIONS – Aim To identify To decide When (those with injury) (which ones (how quickly need laparotomy) this must be undertaken)
  13. 13. DIAGNOSTIC STRATEGY cont.. <ul><li>BASIC DATA </li></ul><ul><li>Complete haemogram with hematocrit, ABG, Electrocardiogram </li></ul><ul><li>Renal function tests </li></ul><ul><li>Urine analysis – </li></ul><ul><li>+nce of hematuria – genito urinary injury </li></ul><ul><li>-nce of hematuria – does not rule out it </li></ul><ul><li>Serum amylase / lipase or liver enzymes -  se -suspicion of intraabdominal injuries </li></ul>
  14. 14. DIAGNOSTIC STRATEGY cont… <ul><li>Chest radiograph – </li></ul><ul><li>Pneumothorax/hemothorax </li></ul><ul><li>Raised left/right hemidiaphragm – </li></ul><ul><li>perisplenic/hepatic hematoma. </li></ul><ul><li>Lower ribs fracture – liver/spleen injury. </li></ul><ul><li>Abdominal contents in the chest – </li></ul><ul><li>ruptured hemidiaphragm </li></ul><ul><li>Abdominal radiographs – </li></ul><ul><li>Pneumoperitoneum – perforation of hollow viscus </li></ul><ul><li>Ground glass appearance – </li></ul><ul><li>massive hemoperitoneum </li></ul>
  15. 15. DIAGNOSTIC STRATEGY <ul><li>Abd. Radiograph cont… </li></ul><ul><li>Dilated gut loops- retroperitoneal hematoma or injury </li></ul><ul><li>Retroperitoneal air outlining the right kidney – duodenal injury </li></ul><ul><li>Double wall sign – air inside and outside the bowel </li></ul><ul><li>Distortion or enlargement of outlines of viscera – hematoma in relation to respective organs </li></ul>
  16. 16. DIAGNOSTIC STRATEGY cont… <ul><li>Abd. Radiograph cont… </li></ul><ul><li>Medial displacement of stomach – splenic hematoma </li></ul><ul><li>Obliteration of Psoas shadow – retroperitoneal bleeding </li></ul><ul><li>Pelvic bone fracture – bladder/urethral/rectal injury </li></ul><ul><li>Fracture vertebra – ureter injury / retroperitoneal hematoma </li></ul>
  17. 17. <ul><li>INDICATIONS FOR FURTHER TESTING </li></ul><ul><li>Unexplained haemorrhagic shock </li></ul><ul><li>Major chest or pelvic injuries </li></ul><ul><li>Abdominal tenderness </li></ul><ul><li>Diminished pain response due to </li></ul><ul><ul><li>Intoxication </li></ul></ul><ul><ul><li>Depressed level of consciousness </li></ul></ul><ul><ul><li>Distracting pain </li></ul></ul><ul><ul><li>Paralysis </li></ul></ul><ul><li>Inability to perform serial examination </li></ul>
  18. 18. <ul><li>FOUR QUADRANT TAP: </li></ul><ul><li>Overall accuracy – about 90% </li></ul><ul><li>Positive tap – obtaining 0.1 ml or more of non clotting blood </li></ul><ul><li>Negative tap does not rule out haemorrhage </li></ul><ul><li>DIAGNOSTIC PERITONEAL LAVAGE </li></ul><ul><li>Criteria for positive tap – </li></ul><ul><li>Gross bloody tap </li></ul><ul><li>>1,00,000 RBCs per mm </li></ul><ul><li>> 500 white blood cells per mm </li></ul><ul><li>Elevated amylase level </li></ul><ul><li>Presence of bile or bacteria or faeces </li></ul>
  19. 19. <ul><li>ULTRASOUND - </li></ul><ul><li>FAST EXAMINATIONS ( focused assessment with sonography for trauma ). </li></ul><ul><li>Advantages </li></ul><ul><li>Inexpensive, noninvasive and portable </li></ul><ul><li>Performed by emergency physicians and surgeons trained in performing FAST examinations. </li></ul><ul><li>Avoids risks associated with contrast media </li></ul><ul><li>Confirms presence of hemoperitoneum in minutes </li></ul><ul><ul><li>Deceases time to laparotomy </li></ul></ul><ul><ul><li>Great adjunct during multiple casualty disasters </li></ul></ul><ul><li>Serial examination can detect ongoing hemorrhage </li></ul><ul><li>Differentiates pulseless electrical activity from extreme hypotension </li></ul><ul><li>With pregnant trauma patients, determines gestational age and fetal viability </li></ul>
  20. 20. <ul><li>Disadvantages - </li></ul><ul><li>A minimum of 70 ml of intraperitoneal fluid for positive study. </li></ul><ul><li>Accuracy is dependent on operator / interpreter skill and is decreased with prior abdominal surgery. </li></ul><ul><li>Technically difficult with – obese, ileus or subcutaenous emphysema is present </li></ul><ul><li>Does not define exact cause of hemoperitoneum </li></ul><ul><li>Sensitivity is low for small-bowel and pancreatic injury </li></ul><ul><li>Sensitivity – 69%-99% </li></ul><ul><li>Specificity – 86%-98% </li></ul>
  21. 21. <ul><li>Technique - </li></ul><ul><li>Four basic transducer positions used to find abdominal fluid. </li></ul><ul><li>Subxiphoied – hemopericardium </li></ul><ul><li>Right upper abdominal quadrant - </li></ul><ul><li>fluid in Morrison’s pouch </li></ul><ul><li>Left upper abdominal quardant – </li></ul><ul><li>fluid in perisplenic space </li></ul><ul><li>Suprapubic – </li></ul><ul><li>fluid in Douglas pouch </li></ul>
  22. 22. <ul><li>ABDOMINAL CT SCAN </li></ul><ul><li>-Latest generation of helical and multislice scanners provides rapid and accurate diagnostic information. </li></ul><ul><li>-Criterion standard for solid organ injuries. </li></ul><ul><li>-Help quantitate the amount of blood in the abdomen and can reveal individual organs with precision. </li></ul>
  23. 23. TABLE Diagnostic Modalities in Abdominal Trauma   PERITONEAL LAVAGE ULTRASOUND CT SCAN Use Records intra-abdominal haemorrhage in stable/unstable trauma Reveals intra-abdominal haemorrhage in stable and unstable in patients Reveals organ of injury and extent of blunt/penetrating abdominal trauma in stable patients Contra-indications  Urgent demand for laparotomy  Prior abdominal surgery  Pregnancy and obesity  Urgent demand for laparotomy  Obesity and subcutaneous emphysema  Need for emergency laparotomy in an unstable patient    Unco-operative patients  Allergy to contrast material Drawback Unreliable in retroperitoneal and diaphragmatic trauma Failes to show small amount of fluid  Unreliable in detection of rupture of bowel and diaphragmatic injuries    Time consuming    High cost
  24. 24. TABLE Diagnostic Modalities in Abdominal Trauma cont….. * Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in blunt abdominal trauma. J Trauma 29:242, 1999. ** Meyer D M, Thal E R, Weigelt J A, et al: The role of abdominal CT in the evaluation of stab wounds to the back. J Trauma 29:1226, 1999. PERI-TONEAL LAVAGE ULTRA-SOUND CT SCAN Sensitivity 100%  84%  89%** Specificity 97%  88%  98%** Accuracy 99%  86%  97% 
  25. 25. LAPAROSCOPY <ul><li>Advantages </li></ul><ul><li>extent of organ injuries and determines the need for laparotomy </li></ul><ul><li>Defines which intraabdominal injuries may be safely managed nonsurgically </li></ul><ul><li>More sensitive than DPL or CT in uncovering </li></ul><ul><ul><li>Diaphragmatic injuries </li></ul></ul><ul><ul><li>Hollow viscus injuries </li></ul></ul><ul><li>Surgery can be done in same sitting </li></ul><ul><ul><li>With laparoscope with minimal trauma </li></ul></ul><ul><ul><li>Open surgery </li></ul></ul><ul><li>Sampling for HPR can be taken </li></ul>
  26. 26. <ul><li>Disadvantages: </li></ul><ul><li>pneumoperitoneum may elevate ICP </li></ul><ul><li>General anesthesia usually necessary </li></ul><ul><li>Patient must be hemodynamically stable </li></ul><ul><li>Complications: </li></ul><ul><li>bleeding or injury </li></ul><ul><li>Gas embolism and pneumoperitoneum </li></ul>LAPAROSCOPY cont…
  27. 27. LAPAROTOMY <ul><li>INDICATIONS </li></ul><ul><li>Absolute criteria </li></ul><ul><li>Peritonitis (gross blood, bile or faeces) </li></ul><ul><li>Pneumoperitoneum or pneumoretroperitoneum </li></ul><ul><li>Evidence of diaphragmatic defect </li></ul><ul><li>Gross blood from stomach or rectum </li></ul><ul><li>Abdominal distension with hypotension </li></ul><ul><li>Positive diagnostic test for an injury requiring operative repair </li></ul>
  28. 28. NON OPERATIVE INJURY MANAGEMENT <ul><li>General considerations </li></ul><ul><li>criteria for non operative management </li></ul><ul><li>Patient hemodynamically stable after initial resuscitation </li></ul><ul><li>Continuous patient monitoring for 48 hrs </li></ul><ul><li>Surgical team immediately available </li></ul><ul><li>Adequate ICU support and transfusion services available </li></ul><ul><li>Absence of peritonitis </li></ul><ul><li>Normal sensorium </li></ul>
  29. 29. NON OPERATIVE INJURY MANAGEMENT <ul><li>- Angioembolization may be alternative to surgical intervention </li></ul><ul><li>- All patients with solid organ injury managed nonoperatively require admission for observation, serial hematocrit measurement, and repeat imaging </li></ul>
  30. 30. ORGAN INJURIES <ul><li>SOLID ORGANS - </li></ul><ul><li>Solid organs most commonly injured in blunt traumas </li></ul><ul><li>In decreasing incidence of injury </li></ul><ul><ul><li>Spleen, liver, kidneys, intraperitoneal small bowel, bladder, colon, diaphragm, pancreas and duodenum </li></ul></ul>
  31. 31. <ul><li>HOLLOW VISCERA : </li></ul><ul><li>duodenum commonly injured </li></ul><ul><li>Small bowel injured at relatively fixed areas (duodenojejunal flexure and ileocaecal junction) by shearing force </li></ul><ul><li>Colon relatively protected. </li></ul><ul><ul><li>Gaseous distension of caecum – most vulnerable part as fixed. </li></ul></ul><ul><li>Stomach rarely injured – compression cause esophagogastric junction bursting </li></ul>
  32. 32. RETROPERITONEUM AND UROGENITAL TRACT <ul><li>Kidney injury - common next to spleen and liver </li></ul><ul><li>Pancreatic injury - 4% cases of trauma </li></ul><ul><li>Bladder - most commonly injured extra peritoneally by shearing at the vesico urethral junction. </li></ul><ul><li>- intraperitoneally by blunt force on distended bladder </li></ul><ul><li>Rupture of prostatic urethra by shear forces is commonly seen with haemorrhage </li></ul>
  33. 33. CHILDHOOD TRAUMA <ul><li>Blunt trauma secondary to MVAs, falls or child abuse is primarily responsible for 90% of childhood injuries. </li></ul><ul><li>Predominance - Solid organ abdominal injuries. </li></ul><ul><li>Non-op. management – 90% success rate </li></ul><ul><li>(standard of care in solid organ injuries) </li></ul><ul><li>Overall mortality – approx 15% or < </li></ul><ul><li>(if major vascular injuries excluded) </li></ul><ul><li>Mortality from severe blunt trauma abdomen is higher than penetrating injuries </li></ul>
  34. 34. CHILDHOOD TRAUMA cont… <ul><li>General Principles - </li></ul><ul><li>Understanding anatomic and physiologic characteristics unique to children. </li></ul><ul><li>Dose according to bodyweight </li></ul><ul><li>Resuscitation - maintenance of ABC </li></ul><ul><li>(golden hour) IV fluids – intraosseus (if needed) </li></ul><ul><li>Nasogastric tube insertion </li></ul><ul><li>Catheterization </li></ul><ul><li>Normothermia maintenance </li></ul>
  35. 35. PROTOCOL FOR BLUNT TRAUMA ABDOMEN MANAGEMENT
  36. 36. RECENT TECHNIQUES <ul><li>TRAUMA LAPAROTOMY </li></ul><ul><li>DAMAGE CONTROL LAPAROTOMY </li></ul><ul><li>Aim : </li></ul><ul><ul><li>Control of haemorrhage and limitation of contamination by rapid and temporary means </li></ul></ul><ul><li>Technique : </li></ul><ul><ul><li>Abdominal packing for visceral bleeding </li></ul></ul><ul><ul><li>Vascular shunting – major vessel injury </li></ul></ul><ul><ul><li>Control of contamination – by stapling guns </li></ul></ul><ul><ul><li>Gastrointestinal perforation or pancreatic leakage – by soft clamps or nylon ties </li></ul></ul>
  37. 37. <ul><li>TEMPORARY CLOSURE OF THE ABDOMEN </li></ul><ul><li>Indication – </li></ul><ul><li>- Permanent closure not possible due to need for observation – to avoid second look surgery. </li></ul><ul><li>Techniques - </li></ul><ul><ul><li>By row of towel clips – quickest method of closure and re-opening </li></ul></ul><ul><ul><li>Continuous nylon suture </li></ul></ul><ul><ul><li>With fascia left wide open in both </li></ul></ul><ul><ul><li>Emptied and opened out intravenous fluid bag (‘Bogata bag’) Sutured or stapled to the skin </li></ul></ul><ul><ul><li>“ Opsite” covered abdominal pack </li></ul></ul>
  38. 38. Temporary closure of the abdomen using two Opsite sheets.
  39. 39. NEWER TECHNOLOGIES <ul><li>ROBOTICS – </li></ul><ul><li>Robot assisted surgeries </li></ul><ul><li>(eg. In microsurgical techniques – eliminate hand tremors) </li></ul><ul><li>Trainer robots - </li></ul><ul><li>(eg. Eagle trauma patient simulator) </li></ul><ul><li>INFORMATION TEHCNOLOGY </li></ul><ul><li>Establishment of city emergency medical system (EMS) with personal status monitor (PSM), vehicle status monitor (VSM), global positioning satellite (GPS), and wireless local area network (LAN). </li></ul>
  40. 40. CONCLUSION <ul><li>Controversies regarding management still exist b/c of varied presentation. </li></ul><ul><li>Close supervision with sophisticated infrastructure and quick action significantly reduces mortality. </li></ul><ul><li>Establishment of trauma centres with persons of different specialties working together as a team. </li></ul>
  41. 41. THANK YOU

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