Closed Abdominal Injuries

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Closed Abdominal Injuries

  1. 1. Closed Abdominal Injuries
  2. 2. <ul><li>Classification of Abdominal trauma </li></ul><ul><li>Penetrating trauma </li></ul><ul><li>solid viscera injury </li></ul><ul><li>Blunt trauma </li></ul><ul><li>hollow viscera injury </li></ul><ul><li>Injuries from blunt trauma are more common and more difficult to assess </li></ul>
  3. 3. Mechanism of closed abdominal injury <ul><li>Deceleration forces from motor vehicle accidents or falls may tear organs from their points of fixation </li></ul><ul><li>e.g. liver, bladder, gut </li></ul><ul><li>A steering wheel or other solid object striking the abdomen may disrupt any of the organs that cross the vertebral column </li></ul><ul><li>e.g. pancreas, duodenum, vena cava </li></ul>
  4. 4. Characteristic features of different organ injuries <ul><li>Parenchymal organ injury hollow organ injury </li></ul><ul><li>liver, spleen, kidney stomach, intestine, gallbladder </li></ul><ul><li>internal hemorrhage acute peritonitis </li></ul><ul><li>pulses BP abdominal tenderness </li></ul><ul><li>abdomen soft rigidity </li></ul><ul><li>tenderness not clearly rebound tenderness </li></ul><ul><li>rebound tenderness obvious diminishing of liver dullness </li></ul><ul><li>presence of shifting dullness </li></ul>
  5. 5. Diagnosis— whether there is viscus damage <ul><li>Repeated frequent examination is essential </li></ul><ul><li>Get the history of injuries </li></ul><ul><li>symptoms:abdominal pain, vomiting, nausea, </li></ul><ul><li>blood stained stool, hematuria, </li></ul><ul><li>management after injury </li></ul>
  6. 6. <ul><li>Physical examination </li></ul><ul><li>BP, pulses, temperature, abdominal tenderness, </li></ul><ul><li>rigidity, rebound tenderness, diminishing of liver </li></ul><ul><li>dullness, presence of shifting dullness and alter- </li></ul><ul><li>nation of bowel sound, P.R examination </li></ul><ul><li>Laboratory findings </li></ul><ul><li>intraabdominal bleeding: RBC Hb </li></ul><ul><li>WBC </li></ul><ul><li>pancreatic injury: amylase in urine and blood </li></ul>
  7. 7. The early symptoms of abdominal injury <ul><li>Shock, especially hemorrhagic shock. </li></ul><ul><li>Severe constant abdominal pain, nausea, vomiting </li></ul><ul><li>and signs of acute peritonitis. </li></ul><ul><li>Shifting dullness present and diminished liver dullness </li></ul><ul><li>Vomiting of blood, passing bloody stool or urine </li></ul><ul><li>PR examination: tenderness, pulsating swelling may be detected and there maybe blood on gloves </li></ul>
  8. 8. <ul><li>X-ray examination of the chest and abdomen </li></ul><ul><li>Abdominal puncture </li></ul><ul><li>valuable in difficult cases </li></ul><ul><li>Diagnostic Peritoneal lavage(DPL) </li></ul><ul><li>more reliable technique , accurately reflects the presence of significant visceral damage in about 95% of cases </li></ul>Additional diagnostic modalities
  9. 9. <ul><li>Ultrasonography </li></ul><ul><li>noninvasive, can detect hemoperitoneum and </li></ul><ul><li>solid organ injury </li></ul><ul><li>CT scan --- highly accurate diagnostic modality </li></ul><ul><ul><li>Hemodynamically stable patient with an equivocal </li></ul></ul><ul><ul><li>abdominal examination </li></ul></ul><ul><ul><li>Patient with closed head injury </li></ul></ul><ul><ul><li>Patient with spinal cord injury </li></ul></ul><ul><ul><li>Hematuria in the stable patient </li></ul></ul><ul><ul><li>Patient with pelvic fractures and significant bleeding </li></ul></ul>
  10. 10. <ul><li>Observation </li></ul><ul><li>If the patient still can not be diagnosed with the above methods, the patient must be kept in hospital under strict observation until the diagnosis can be made clearly. </li></ul>
  11. 11. The rules of management during observation <ul><li>Absolute rest </li></ul><ul><li>Restricting of diet and intravenous infusion </li></ul><ul><li>Don’t use morphe or any sedatives </li></ul><ul><li>Measuring BP, pulse rate, respiratory rate and </li></ul><ul><li>temperature at definite intervals </li></ul><ul><li>repeat abdominal examination and blood count </li></ul><ul><li>If there is any doubt of gastric perforation, gastric </li></ul><ul><li>suction and antibiotics should be used </li></ul>
  12. 12. <ul><li>Performing exploratory laparotomy if necessary </li></ul><ul><li>Indication: </li></ul><ul><li>Increased tenderness or rigidity or distension </li></ul><ul><li>Evidence of continuing blood loss that can not be clearly explained by extraabdominal source </li></ul><ul><li>Evidence of developing peritonitis </li></ul><ul><li>The presence of free air on X-ray </li></ul>
  13. 13. <ul><li>Enlarging of intraabdominal mass </li></ul><ul><li>Demonstration of blood, bile, intestinal contents in abdominal puncture </li></ul><ul><li>High amylase level in abdominal fluid </li></ul><ul><li>In the presence of shock with increasing abdominal rigidity and an inadequate response to fluid replacement </li></ul>
  14. 14. Treatment principle <ul><li>Keep the airway free </li></ul><ul><li>Circulatory resuscitation </li></ul><ul><li>laparotomy </li></ul><ul><li>Control of hemorrhage, in extreme cases thoracotomy required </li></ul><ul><li>Contamination from lacerations of the gut should be stopped as quickly as possible </li></ul>
  15. 15. spleen injury <ul><li>Spleen is the most commonly injured intra- </li></ul><ul><li>abdominal organ </li></ul><ul><li>Splenic injury must be suspected in any patient </li></ul><ul><li>with blunt abdominal trauma, especially with left </li></ul><ul><li>lower rib fracture </li></ul><ul><li>Diagnosis is suspected on physical examination, </li></ul><ul><li>and confirmed by abdominal CT scan or explora- </li></ul><ul><li>tory laparotomy for hemoperitoneum </li></ul>
  16. 16. Treatment <ul><li>Splenorrhaphy or partial resection </li></ul><ul><li>Total splenectomy </li></ul><ul><ul><li>hilar vascular injury </li></ul></ul><ul><ul><li>massive subcapsular hematoma </li></ul></ul><ul><ul><li>extensive fragmentation </li></ul></ul><ul><ul><li>total avulsion </li></ul></ul><ul><ul><li>severe associated injuries </li></ul></ul><ul><ul><li>continuing bleeding after attempted splenic repair </li></ul></ul>
  17. 17. <ul><li>Nonoperative management </li></ul><ul><li>delayed spleen rupture must be considered </li></ul><ul><li>due to enlarging subcapsular hematoma </li></ul><ul><li>rupture of a traumatic pseudoaneurysm </li></ul><ul><li>recurrent or ongoing hemorrhage </li></ul>
  18. 18. <ul><li>Liver and Biliary Tree </li></ul><ul><li>The second most commonly injured organ following blunt trauma </li></ul><ul><li>Injury is ofen minor and can be easily managed by direct suture ligation or by using hemostatic agents </li></ul>
  19. 19. Seven basic techniques in operation <ul><li>Suture </li></ul><ul><li>Inflow occlusion </li></ul><ul><li>Packing </li></ul><ul><li>Hepatic artery ligation </li></ul><ul><li>Resection </li></ul><ul><li>Mesh hepatorrhaphy </li></ul><ul><li>Atrial-caval shunting </li></ul>
  20. 20. Common bile duct injury <ul><li>Completely transection or >50% injured </li></ul><ul><li>biliary-enteric anastomosis </li></ul><ul><li>Perforated or <50% injured </li></ul><ul><li>primary repair and place a T-tube </li></ul><ul><li>Cholecystostomy </li></ul><ul><li>cholecystectomy </li></ul>Gallbladder injury
  21. 21. Stomach injury <ul><li>Gastric rupture secondary to blunt trauma is rare </li></ul><ul><li>Iatrogenic gastric rupture </li></ul><ul><li>vigorous ventilation with an endotracheal tube misplaced in the esophagus </li></ul>
  22. 22. <ul><li>If vomitus or gastric aspirate is bloody, stomach injury should be suspected </li></ul><ul><li>At laparotomy, gastrocolic omentum must be widely opened for complete inspection </li></ul>
  23. 23. Treatment <ul><li>Debridement and closure </li></ul><ul><li>Gastric diversion or resection is rarely necessary </li></ul>
  24. 24. Small intestion injury <ul><li>Incidence 5% -- 15% </li></ul><ul><li>Mechanism </li></ul><ul><ul><li>Crush injury between the vertebrae and anterior abdominal wall </li></ul></ul><ul><ul><li>Sudden increase of intraluminal pressure </li></ul></ul><ul><ul><li>Tear at the junction of a mobile and a fixed segment of bower </li></ul></ul>
  25. 25. Treatment <ul><li>Simple laceration --- suture, avoid excessive narrowing of the bowel </li></ul><ul><li>Extensive damage or multiple tears situated fairly close --- resection of the involved segment </li></ul>
  26. 26. Colon injury <ul><li>Most colon injuries can only be definitively recognized at laparotomy. </li></ul><ul><li>Early diagnosis and treatment dramatically reduce infection complications. </li></ul>
  27. 27. Four tecniques in the management <ul><li>Primary repair </li></ul><ul><li>Resection and primary anastomosis </li></ul><ul><li>Exteriorization of repair </li></ul><ul><li>colostomy </li></ul>
  28. 28. Guidelines of repair instead of colostomy <ul><li>Operation within 4 to 6 hours </li></ul><ul><li>Less than 6 units of blood transfusion </li></ul><ul><li>No evidence of prolonged shock or hemodynamic instability </li></ul><ul><li>Minimal soilage of peritoneal cavity </li></ul><ul><li>Injury limited to one aspect of the colon </li></ul><ul><li>No associated colonic vascular injury </li></ul><ul><li>No loss of abdominal wall </li></ul>
  29. 29. Rectum injury <ul><li>Abdominal x-ray films are obtained for the determination of retroperitoneal air </li></ul><ul><li>Proctosigmoidoscopy performed for either direct visualization of the injury or for the evidence of hemorrhage </li></ul><ul><li>Transpelvic gunshot wounds should undergo celiotomy </li></ul>
  30. 30. Treatment <ul><li>Full thickness rectal wounds above the dentate line --- primary closure combined with a diverting colostomy </li></ul><ul><li>Wounds below the dentate line --- debridement accompanied by drainage </li></ul>
  31. 31. <ul><li>Wounds above the levators with penetration of the pelvirectal space </li></ul><ul><ul><li>Closure, if possible </li></ul></ul><ul><ul><li>Proximal diverting colostomy </li></ul></ul><ul><ul><li>Presacral (retrorectal) drainage </li></ul></ul><ul><ul><li>Irrigation of the rectal stump </li></ul></ul>

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