• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Abd Trauma - Cindy K..
 

Abd Trauma - Cindy K..

on

  • 2,960 views

 

Statistics

Views

Total Views
2,960
Views on SlideShare
2,960
Embed Views
0

Actions

Likes
1
Downloads
155
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • EVALUATION AND INDICATIONS FOR CELIOTOMY
  • Seat belt sign a/w intest injury esp at prox jej and terminal ileum.
  • IN the past, mandatory exploration for suspected abdominal injury resulted in unacceptably high negative and nontherapeutic laparotomy rates, which are associated with 18% and 45% morbidity rates, respectively. We have evolved to using diagnostic modalities to identify those who do not require a laparotomy. Low specificity of DPL is reason that it’s associated with 20%rate of nontherapeutic ex-lap.
  • + DPL: Initial aspiration blood >=5cc Rbc >100,000 mm3 WBC>500mm3 Presence of bile, bacteria, food particles Presence of lavage fluid via foley or chest tube or NG Presence of pleural effusion on postlavage cxr, suggesting occult diaphragmatic rupture.
  • 12yoM boogi boarding, presented 16h after injury. HR 130, BP 100/60. RUQ pain with guarding. Non op.
  • Both were sustained by kids boogie boarding, both managed nonoperatively. Spleen: 14yo boy rammed into boogi board, presented 6h later with worsening LUQ pain. Tachy to 130, BP 100/60. Non op. no transfusions.
  • In absence of peritonitis, HD instability, intraab fluid on FAST, may stratify by loci. 25% of stab wounds fail to penetrate peritoneal cavity, therefore selective mgmt of stab wounds. This practice is supported by complication rates of 8% and 41% for negative laparotomies or nontherapeutic laparotomies. Avg LOS for uncomplicated nontherapeutic laps 5.1 days; Avg LOS for complicated nontherap laps 11.9 days. Nance etal: 2000pts. Clinical obs with serial PE in stable pts with SW. Demetriades/Robinowitz: 651 pts. 53% laparotomy, 47% obs. Of Obs, only 2.9% req’d subsequent surgery. Overall incidence of negative laparotomy 5%. Anterior ab: ant to ant ax line, below costal margin, above inguinal lig. in absence of hypotension, peritonitis, evisceration, intraabdominal fluid on FAST - Flank: b/n anterior and posterior axillary lines, lower ribs to iliac crest Back: posterior to post ax lines. If no anterior abd tenderness… Lower chest: below nipples in ant/lat/post Peristernal potential mediastinal: cardiac silhouette, base of neck in suprasternal notch.
  • 35% of pts with ant ab wounds will not have fascial penetration Even if anterior fascia penetrated, still 25% non therapeutic laparotomy rate.
  • Due to retroperitoneal attachments of L and R colon, and duodenum, need triple contrast CT.
  • Admit for obs due to risk for hepatic/posterior duodenal injury
  • Lower Chest: potential for intra-thoracic and intraabdominal injury and transdiaphragmatic traverse. Pressure gradient b/n abdominal and pleural space may cause diaphragm wound enlgment and herniation of ab contents. Thoracoscopy to visualize diaphragm. Diagnostic dilemma.
  • Peristernal potential mediastinal: Cardiac tamponade, pneumothorax. CVP monitoring, U/S to dx. Observe atleast 6h, repeat CXR for developing PTX.
  • In absence of peritonitis, HD instability, intraab fluid on FAST, may stratify by loci. Anterior ab: ant to ant ax line, below costal margin, above inguinal lig. in absence of hypotension, peritonitis, evisceration, intraabdominal fluid on FAST - Flank: b/n anterior and posterior axillary lines, lower ribs to iliac crest Back: posterior to post ax lines. If no anterior abd tenderness… Lower chest: below nipples in ant/lat/post Peristernal potential mediastinal: cardiac silhouette, base of neck in suprasternal notch.

Abd Trauma - Cindy K.. Abd Trauma - Cindy K.. Presentation Transcript

  • Abdominal Trauma Cindy Kin Trauma Conference 8 January 2007 Stanford General Surgery
  • Blunt Abdominal Trauma
    • Mechanisms
    • Direct impact
    • Acceleration-deceleration forces
    • Shearing forces
    • No correlation between size of contact area and resultant injuries.
    • Abdomen = potential site of major blood loss.
  • Initial Evaluation and Treatment
    • Is there a surgical intraabdominal injury?
    • PE: guarding, peritoneal signs, tenderness, nausea. DRE.
    • Lower rib fxs: 10-20% a/w spleen/liver injury
    • Seatbelt sign a/w intestinal injury and mesenteric tears.
    • Direct blunt trauma: rupture/tear of solid organs.
    • Flank pain or contusion often late signs of retroperitoneal bleed
    • Rapid resuscitation
    • CXR, Pelvic X-ray
    • FAST v DPL v CT
    • Labs: Hct, WBC, amylase, UA, ABG, T+C
  • Blunt Abdominal Trauma
    • INDICATIONS for CT
    • Blunt trauma with closed head injury
    • Blunt trauma with spinal cord injury
    • Gross hematuria
    • Pelvic fx, +/- suspected bleeding
    • Pt requiring serial exams, but will be lost to PE for prolonged period (ie orthopedic procedures, general anesthesia)
    • Pts with dulled or altered sensorium
    • CONTRAINDICATIONS: unstable patients
  • Blunt Abdominal Trauma 0.5% miss intestinal perforation; cannot distinguish blood v bowel contents Cannot evaluate retroperitoneum. Cannot identify source of fluid. Stable pts only Drawbacks 85% 88-90% 95% Specificity 100% 90-92% 97% Sensitivity 95% 95-99% 96% Accuracy DPL FAST CT
  • Blunt Abdominal Trauma
    • Shock with
    • expanding abdomen,
    • pnemoperitoneum,
    • retroperitoneal air
    INDICATIONS FOR LAPAROTOMY Imaging: CXR FAST/DPL/CT Stable w/ peritoneal signs Peritoneal signs, HD unstable, sepsis + equivocal Observe, +/- re-image
  • Blunt Abdominal Trauma
    • ROLE OF DIAGNOSTIC LAPAROSCOPY
    • Hemodynamically stable patients
    • Inadequate/equivocal FAST or borderline DPL (80K-120K RBC/HPF)
    • Intermittent mild hypotension or persistent tachycardia
    • Persistent abdominal signs/symptoms
    • Potential to decrease # of nontherapeutic laparotomies
  • Blunt Abdominal Trauma
    • PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME ON FAST EXAM
    • Hemoperitoneum score on ultrasound a better predictor of need for therapeutic laparotomy than admission blood pressure and/or base deficit.
    • Hemoperitoneum characterized by measurement and distribution, scored
    • Ultrasound score >=3 statistically more accurate than combination of SBP and base deficit in determining which patient will undergo a therapeutic abdominal operation
    • 83% sensitivity, 87% specificity, 85% accuracy
      • McKenney et al, J Trauma 50:650-656, 2001
  • Blunt Abdominal Trauma
    • HEPATIC AND SPLENIC INJURIES
    • Unstable patients: mandatory laparotomy
    • Stable patients: selective nonoperative approach
    Hepatic injury -Usually venous bleeding -Grade I-III: 94% success w/ nonop treatment -Grade IV-V: 20% amenable to nonop tx -HD stability, stable Hct, observation -Complications: delayed hemorrhage, bile leak, biloma, intra/peri hepatic abscess. -If stable with ongoing bleeding - angiographic embolization
  • Blunt Abdominal Trauma
    • SPLENIC INJURIES
    • Often arterial hemorrhage, therefore nonoperative management less successful.
    • Predictive factors for nonop success:
      • Localized trauma to flank/abdomen
      • Age<60
      • No associated trauma precluding obs
      • Transfusion <4u prbcs
      • Grade I-III
    • Grade IV-V: almost invariably require operative intervention
    • Delayed hemorrhage (hours to weeks post-injury): 8-21%
  • Blunt Abdominal Trauma
    • RETROPERITONEAL HEMORRHAGE
    • Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx, retroperitoneal bowel.
    • Minimal signs on examination; flank pain and contusion are late findings
    • FAST/DPL negative; CT can identify
  • Blunt Abdominal Trauma
    • DUODENAL AND PANCREATIC INJURY
    • Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitoneal air on plain abdominal films.
    • DPL unreliable.
    • At laparotomy, central upper abdominal retroperitoneal hematoma, bile staining, or air: mandates visualization and examination of panc/duo
    • Duodenal injury:
      • 80% lacs (G I-III) - primary repair
      • 10-15% RYDJ, pyloric exclusion, Whipple
    • Pancreatic injury
      • Late complications: time from injury to tx
        • Abscess, pseudocyst, fistula.
  • Blunt Abdominal Trauma
    • DIAPHRAGMATIC RUPTURE
    • 3-5% of all abdominal injuries, L>R
    • May p/w few signs, need high index of suspicion
      • Injury mechanism: compartment intrusion, deformity of steering wheel, need for extrication, fall from great height
      • Prominence/immobility of L hemithorax
      • NGT in chest, bowel sounds in thorax
      • CXR: (50% with non-dx initial CXR):
        • Obliteration of L diaphragm on CXR
        • Elevation/irregularity of costophrenic angle
        • Pleural effusion
    • Confirm with GI contrast studies, dx laparoscopy
    • Ex-lap and repair
  • Blunt Abdominal Trauma
    • SMALL BOWEL INJURY
    • Mechanism: rapid deceleration with compression, shearing
    • Often at points of fixation: Treitz, ileocecal valve, prior adhesions, mesentery.
    • Chance fracture (transverse fx of lower thoracic/lumbar vertebral body) raises index of suspicion for SB injury
    • Dx: DPL may be (-) for 6-8h after intestinal perforation, Clinical signs absent until 6-12h post-injury.
    • Delayed perforation: due to direct injury, transmural contusion, ischemia from mesenteric vascular injury; usually presents w/in days.
  • Blunt Abdominal Trauma
    • INJURY TO COLON AND RECTUM
    • Mechanism: rapid deceleration with steering wheel compression
    • uncommon
    • Disruptions of colonic wall or avulsion injury of mesentery
    • Present with hemoperitoneum, peritonitis.
  • Penetrating Abdominal Trauma
    • Evaluation
    • Any penetrating wound between nipples and gluteal crease = potential intra-abdominal injury.
    • Stab wounds: stratify based on location
    • GSW: higher potential for serious injury.
  • Penetrating Abdominal Trauma
    • Evaluation of Stab Wounds
    • Local exploration
    • DPL
      • 5cc gross blood on aspiration
      • >20K RBC/mm3
      • >500 WBC/mm3
      • >175U amylase/100mL
      • Bacteria
      • Bile, Food particles
    • CT
      • Limited ability to dx hollow organ injury
      • Useful for posterior SW
    • FAST
      • Limited, high false negative rate
      • Useful for pericardial injuries
    • Diagnostic laparoscopy
      • Useful for assessing peritoneal penetration, diaphragm injury
      • Shorter LOS than negative laparotomy
  • Penetrating Abdominal Trauma
    • Stab Wounds: Stratification by loci
    Lower Chest Anterior Abdominal Flank Peristernal Potential Mediastinal Back
  • Penetrating Abdominal Trauma
    • Stab Wounds: Stratification by loci
    Lower Chest Anterior Abdominal Explore locally, manage expectantly with serial PE Flank Peristernal Potential Mediastinal Back
  • Penetrating Abdominal Trauma
    • Stab Wounds: Stratification by loci
    Lower Chest Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal Back
  • Penetrating Abdominal Trauma
    • Stab Wounds: Stratification by loci
    Lower Chest Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal Back admit for obs
  • Penetrating Abdominal Trauma
    • Stab Wounds: Stratification by loci
    Lower Chest ?Thoracoscopy, Laparoscopy Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal Back admit for obs
  • Penetrating Abdominal Trauma
    • Stab Wounds: Stratification by loci
    Lower Chest ?Thoracoscopy, Laparoscopy Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal CVP monitor, U/S Observe >6h, repeat CXR Back admit for obs
  • Penetrating Abdominal Trauma
    • Gunshot Wounds
    • Usually require urgent exploration
    • Evaluation for peritoneal penetration v tangential GSW.
      • CT, diagnostic laparoscopy
      • Use of DPL controversial due to high false negative rate
    • Ballistics:
      • Civilian=lower velocity handgun missiles; military = higher velocity rifle missiles
      • Permanent and temporary cavities: Yaw, Bullet size and type
      • Shotgun:
        • Short range: high-velocity and more concentrated
        • Distant range: multiple low-velocity projectiles, more diffuse, less severe
    • Antibiotics: cefotetan or cefoxitin in ED
  • Penetrating Abdominal Trauma
    • ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATING GSW AND NEED FOR LAPAROTOMY
    • 66 GSW underwent DL, 2/3 of GSW in upper torso
    • Peritoneal penetration ruled out in 62%
    • 29% had therapeutic ex-lap, 5% had non-therapeutic ex-lap, 4% had negative ex-lap
    • Hospital stay:
      • 4.3 days - negative DL and associated injuries
      • 8.6 days - laparotomy
      • 1.1 days - negative DL and no associated injuries.
      • Fabian et al, Ann Surg 1993; 217:557
  • Penetrating Abdominal Trauma
    • IMPACT OF DIAGNOSTIC LAPAROSCOPY ON
    • NEGATIVE LAPAROTOMY RATE
    • Retrospective review 817 pts who underwent ex-lap for abdominal GSW over 4yr: negative ex-lap rate = 12.4%
      • 22% morbidity, LOS 5.1days
    • Review of 85 pts with abdominal GSW evaluated with DL
      • Negative DL in 65%, no missed injuries, no subsequent need for ex-lap;
      • 3% morbidity rate (one pt had urinary retention), LOS 1.4days
      • Positive DL in 35%, 28 of 30 underwent ex-lap, 86% therapeutic and 14% nontherapeutic (remaining 2 were observed for nonbleeding liver lacs)
      • Sosa et al. J Trauma 1995;38(2):194
  • Penetrating Abdominal Trauma
    • IMPACT OF DIAGNOSTIC LAPAROSCOPY ON
    • NEGATIVE LAPAROTOMY RATE
    • Prospective study of 121 patients with tangential GSW, HD stable
    • 65% negative DL
    • Of 25% positive DL, 92.8% (39) underwent ex-lap
      • 82% (32) therapeutic, 15.4% (6) nontherapeutic, 2.5% (1) negative
    • No false negative DLs, no delayed laparotomies
    • Sensitivity for peritoneal penetration 100%
      • Sosa et al. J Trauma 1995;39(3):501