Abd Trauma - Cindy K..

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  • 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..

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

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