ABDOMINAL TRAUMA : AN OVERVIEW Dr S. Lal MS Associate Professor Department of Surgery ESI PGIMSR New Delhi
Introduction• Abdominal trauma is regularly encountered in the emergency department• One of the leading cause of death and disability• Identification of serious intra-abdominal injuries is often challenging• Many injuries may not manifest during the initial assessment and treatment period
Epidemiology• Peak incidence Abdominal Trauma 15 - 30yr• More than 1.5 Lac people die every year as a result of injuries by motor vehicle accident , fall, suicide and homicide• Injury accounts for 10% of all deaths• Estimates indicate that by 2020, 8.4 million people will die yearly.• Prevalence: 13%
Penetrating TraumaPenetrating abdominal trauma has a slightly higher mortality rateSecond most common cause of abdominal injury
Gunshot InjuryGunshot and stab wounds combine to cause 95% ofpenetrating abdominal injuries.
Prehospital Care• The goal of prehospital is to deliver the pt to hospital for definitive care as rapidly as possible. „Scoop and Run‟• Maintain airway & start I V line• Care of spinal cord• Communicate to medical control• Rapid transport of patient to trauma centre
Initial Assessment and Resuscitation Primary survey Identification & treatment of life threatening conditions• Airway , with cervical spine precautions• Breathing• Circulation• Disability• Exposure
Emergency Care• I V fluids• Control external bleeding• Dressing of wounds• Protect eviscerated organs with a sterile dressing• Stabilize an impaled object in place• Give high flow oxygen• Immobilize the patient with a fractured pelvis• Keep the patient warm• Analgesics
Secondary Survey• General &Systemic Examination-to identify all occult injuries .• Special attention to Back, Axilla , Perineum• PR - sphincter tone ,bleeding ,perforation , high riding prostate• Foley‟s catheter- monitor urine out put• Nasogastric tube
Secondary Survey(contd.)AMPLE HistoryA: AllergyM: MedicationsP: Past medical historyL: Last mealE: Event - What happened
Examination• Laceration• Abrasion• Entry/Exit wounds• Involvement chest & Head injury• Seat Belt Sign
ExaminationCullen’s Sign:1918Bluish discoloration around umbilicusDiffusion of blood along periumbilical tissues or falciform ligamentHemoperitoneumSevere pancreatitis
ExaminationGrey-Turner’s Sign: (1877-1951)Bluish discoloration of the flanksRetroperitoneal Hematomahemorrhagic pancreatitis.Kehr’s sign (1862-1916).Referred pain, Right shoulder irritation of the diaphragm(Splenic injury, free air, intra-abdominal bleeding)
ExaminationBalance’s SignDullness on percussion of the left upper quadrantruptured spleenLabia and Scrotum : Pooling of blood fromabdominal and pelvic cavities.
ExaminationAuscultation :1. Bowel sounds in the thoracic cavity (Diaphragmatic rupture) 2. HaemothoraxPalpation: -Mass -Tenderness -Signs of peritonitis -# Ribs -Chest & Pelvic compression test
Focused Assessment with Sonography in Trauma (FAST)• First used in 1996• Rapid , Accurate• Sensitivity 86- 99%• Can detect 100 mL of blood• Cost effective• Four different views- Pericardiac Perihepatic Perisplenic Peripelvic space• Eliminates unnecessary CT scans• Helps in management plan
Plain X-Ray Chest & Abdomen• Pneumotharax, Haemothorax• Free air under diaphragm• Nasogastric tube, bowel loops in the chest• Elevation of the both /Single diaphragm• Lower Ribs # -Liver /Spleen Injury• Ground Glass Appearance – Massive Hemoperitoneum• Obliteration of Psoas Shadow –Retroperitoneal Bleeding• #vertebra
USGAdvantage Disadvantage• Easy & Early to Diagnose . Examiner Dependent• Noninvasive • Obesity• No Radiation Exposure • Gas interposition Resuscitation/Emergency • Low Sensitivity for free fluid room less 500 mL Used in initial Evaluation • False –Negative retroperitoneal & Hallow Low cost viscus injury
Paracentasis• Four quadrant aspiration of abdomen• A Positive tap – blood , air , bile stained fluid• Negative tap doesn‟t rule out injury.• False negatives are as high as 22-60%
Diagnostic Peritoneal Lavage• First described in 1965• Rapid & Accurate test used to identify intra-abdominal injuries• Predictive value of greater than 90%• The RBC count for lavage fluid is > 1,00,000/cu m.m.• A WBC count > 500/cu m.m.• Test is highly sensitive to presence of intraperitoneal blood• However specificity is low
CT Scan•Gold Standard•Haemodynamically Stable• Provides excellent imaging ofpancreas, duodenum and Genitourinary system•Standard for detection of solid organs injury.• Determines the source and amount of bleeding• Can reveal other associated injuries e.g.Vertebral & Pelvic # & injury in the thoraciccavity .•High Specificity-95%
CT ScanContraindication:• Clear indication for Laparotomy• Haemodynamically Unstable• Allergy to contrast media
DIAGNOSTIC LAPAROSCOPY• Haemodynamically stable patients• Inadequate/equivocal USG• Mild hypotension or persistent tachycardia• Persistent abdominal signs/symptoms• It decreases non-therapeutic laparotomies• Useful in penetrating injury• Limitation :Retroperitoneal Injury
Solid Organ Injuries• Grading of injured solid organs such as Spleen, Liver & Kidneys are on the basis of subcapsular hematoma ,capsular tear, parenchymal lacerations & avulsion of vascular pedicle• Bleeds significantly and cause rapid blood loss• Difficult to identify injury by physical exam• Repeated assessment is required to make the diagnosis• Slowly oozing blood into peritoneal cavity
SPLENIC INJURY• Most common intra- abdominal organ to injured (40-55%)• 20% of splenic injuries due to left lower rib fractures• Commonly arterial hemorrhage• Conservative management : -Hemodynamic stability - Negative abdominal examination -Absence of contrast extravasation in CT - Absence of other indication of Laprotomy -Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm)Monitoring• Serial abdo. Examinations & Haematocrit are essential• Success rate of conservative m/m is >80%
Splenic Injuries Operative ManagementCapsular tears (I)- Compression & topical haemostaticagentDeep Laceration (II)- Horizontal mattress suture or SplenorrhaphyMajor Laceration not involving hilum (IV)- Partial SplenectomyHillar injury (V)–Total SplenectomyGrade IV-V: almost invariably require operativeinterventionSuccess rate of Splenic salvage procedure is 40-60%
Liver injury• Liver is the largest organ in abdomen• 2nd most common organ injured (35- 45%) in BTA• Driving and fighting responsible for 50% of deaths due to liver injury• Usually venous bleeding• 85% of all patients with blunt hepatic trauma are stable• CT is the mainstay of diagnosis in stable pt.
Liver Injury• 50% liver injury have stop bleeding spontaneously by the time of surgeryNon Operative m/m• Haemodynamically Stable• No other intra-abdominal injury require surgery• < 2 units of BT required• Hemoperitoneum <500 ml on CT• Grade I-III(subcapsular & intr-perenchymal hematoma)
Liver Injury Operative m/m• Packing - Bleeding can be stopped by packing of abdomen -Pack removed after 48 hr -haemostatic agents -34 % survival in packing only
Liver Injury Operative Management(Contd.)• Suturing: -Simple suture -Deep mattress suture• Laceration: -Mesh hepatorrhaphy -Omental flap to cover the laceration - Debridement• Lobar Resection• Liver Transplantation• Ligate or repair damaged blood vessels & bile duct• Mortality of liver injury is 10%
Pancreatic Injury• Rare 10-20% of all abdominal injury• Crush , Direct blow to abdo & Seat belt injury• Associated with abdo. Duodenal injury, Vascular injury & liver injury• Diagnosis – Difficult, High index of suspicion• CECT Scan is helpful• Serum amylase is a poor indicator• Usually diagnose on Laparotomy• Distal Pancreatic injury - Distal resection• Pancreaticojejunostomy – Injury to Ampulla of Vater, Head & Body of Pancreas
Renal Injury .Classification of Injury• Grade I : Contusion or Subcapsular Hematoma• Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation• Grade III: Laceration >1cm with urinary Extravasation• Grade IV: Parenchymal Laceration deep to CM Junction• Grade V: Renovascular injury
Management of Renal InjuryAbout 85% of blunt renal trauma can be manage by conservativelyRenal Contusion : ConservativelyRenal exploration : Indication• Deep cortico-medullary Laceration with extravasation• Large perinephric Hematoma• Renovascular injury• Uncontrolled bleedingBefore Nephrectomy ,Contralateral Kidney should be assessed
Diaphragmatic Injury• Incidence -0.8%-1.6% in BTA• High index of suspicion required , may be missed.• 40 to 50% are diagnosed immediately• Presentation may be delayed• Imaging Nasogastric tube seen in the thorax Abdominal contents in the thorax Elevated hemidiaphragm (>4 cm Lt vs Rt) Distortion of diaphragmatic margin.• Lt- 69% , Rt -24% B/L- 15%
Diaphragm Rupture /Hernia• S Lal, Y Kailasia , S Chouhan , APS Gaharwar, GP Shrivastava . Delayed presentation of post traumatic diaphragmatic hernia. JSCR 2011. 7:6
Diaphragm Rupture /HerniaS Lal, Y Kailasia, S Chouhan, APS Gaharwar, GP Shrivastava. Delayed presentation ofpost traumatic diaphragmatic hernia. JSCR 2011. 7:6
Hollow Viscus InjuriesGastric Injury : Penetrating trauma MC Blunt trauma abdomen 1%Causes Penetrating Injury -Crushing Against the Spine -CPR -Vigorous Ventilation with ET Tube in the Esophagus -Heimlich ManeuverDiagnosis : X-Ray chest & Abdomen CT scan Diagnostic Peritoneal Lavage During Surgical ExplorationT/t : Expl. Laparotomy with Primary Repair
Hollow Viscus Injuries (Contd.) DuodenumIsolated Duodenum injury rare Incidence - 3-5%Cause :Penetrating injury: mc Steering wheel injury Assault FallAssociated with other intra-abdominal injuryDiagnosis:Plan X-ray –Free air in abdomen -Intraoperative diagnosisRx : Primary Repair 80% case Roux-en –Y duodenojejunostomy 20%
Hollow Viscus Injuries Small Intestine& Colonic InjuriesCommonly Injured in Penetrating injuryBlunt Trauma -Incidence 5% -20%Mechanism : -Crush Injury -At Fixed point DJ & IC Junction Rx : Exploratory Laprotomy
Bladder Injury• Commonly in BTA• 70% of bladder Injury are associated with pelvic fracture .• HematuriaType 1.Extraperitoneal Rupture-by bony fragment• 2. Intraperitoneal Rupture- at dome when blow in distended bladder• Diagnosis -1. Clinical 2. CystographyT/t 1. Intraperitoneal –trans-peritoneal - closure +SPC 2:Extraperitoneal Rupture : Foley‟s catheter -10 -14 days
Ureteral Injury• Uncommon• Mostly occur after penetrating trauma• Associated with concomitant intra-abdominal or genitourinary injury• Diagnosis -IVP -15-20% Retrograde ureteroscopy - At the time of Laparotomy• Operative procedure Proximal & mid ureter -End to end Anastomosis over DJ Stent Distal –Ureteric Reimplantaion
Vascular Injury• Incidence 5-10%• Highly lethal.• Associated with extremely rapid rates of blood loss• Exposure is difficult in Laparotomy• Initial Control by digital pressure• Heparinized saline (50U/ml) injected in both end of vessel• Rx Lateral suture ,End to end Anastomosis & Interposition graft• Mortality rate is very high
Trauma in Pregnancy• Incidence- 10-20%• Causes: 1.Domestic violence 2.Sexual Assault 3. Accident• Third trimester- mc- balance & coordination disturbed• Multidisciplinary team- Obstetrician, surgeon, and neonatologist• Peritoneal sign are delayed• “Supine hypotensive syndrome” > 20 weeks‟ gestation.COMPLICATIONS• Fetal Injury & Death –fetoplacental injury, maternal shock,• Placental Abruption• Rupture of Uterus
Stab wound to right lower quadrant with caecalevisceration. No colon injury at laparotomy
Penetrating Abdominal Trauma(Contd.) Abdominal Evisceration• Never try to replace organs• Cover with moist gauze, then sterile dressing.• Transport immediately
Gunshot Injury• Handguns, Rifles, and Shotgun• More dangerous than penetrating injury• The degree of injury depends . Amount of kinetic energy imparted by the bullet to the victim Mass of the bullet and the square of its velocity Distance .• Injury multiple organ
Injury Prevention1.Primary: Prevent an injury from its occurrence in the first place: Educational activity such as anti- drink-driving campaigns , speed limit rule -Children should accompanied with parent2.Secondary: Attempts to lesson the consequences of injury – making road & safer car, anti-locking brakes, air bags , helmets, seat belt3. Tertiary: Minimize the effect of injury by health care by individuals & system.
Injury Prevention (Contd.)• Speed is a critical factor ; a 10% increase speed translate into a 40% rise in the case fatality rate.• Use of seat belt reduces the risk of death or serious injury by 45%.• Air Bags reduces the risk of fatal injury by 30% & deaths by 11 %.• Children Below 12yrs should be properly restraints in the back seat.• Motorcycle experience death rate 35 time greater than car.
Summary• Injuries are Preventable• Trauma is a massive & growing health burden worldwide ,which increasingly afflicts the young & productive age group.• Repeated assessment is required to make the diagnosis• Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of Hemoperitoneum• Conservative approach in Liver & Renal Injury• Successful m/m of trauma requires integration of Prehospital ,in-hospital ,& rehabilitative care.