Nath abdominal trauma


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Nath abdominal trauma

  1. 1. Abdominal Trauma Nat Krairojananan M.D., FRCSTDepartment of Trauma and Emergency Medicine Phramongkutklao Hospital
  2. 2. overview• Quick review abdominal anatomy• Review of mechanism of injury• Review of investigation• management
  3. 3. Anatomy of abdomen
  4. 4. External Anatomy FlankAnterior Backabdomen
  5. 5. Visceral organ
  6. 6. visceral organ Retroperitoneal spacePelvic cavity
  7. 7. Abdominal injuries• No.1 Preventable cause of death• Unrecognized• Closed spaces• Multisystem / multiple organs• Need investigations
  8. 8. ATLS protocol Primary survey MaintainC D E A B circulation Stop / seek for bleedingAdjunct to primary survey A Monitoring E B C D investigations
  9. 9. Investigations for abdominal trauma • FAST • DPA (DPL) • CT scan
  10. 10. FAST: Focused Abdominal Sonography for TraumaAdvantage Disadvatage• Good sensitivity • Operator dependent• Easy to use • Poor evaluation for• Repeatable hollow viscus and• No radiologic exposure retropertoneal injury • Negative FAST?• Really excellent test?
  11. 11. DPL: Diagnostic Peritoneal LavageAdvantage Disadvantage• High sensitivity and • Invasive specificity • Poor evaluation for• Hollow viscus injury retropertoneal injury detection
  12. 12. DPL: Diagnostic Peritoneal LavageIndications Interpretation• Equivocal abdominal sign DPL positive in• Unexplained shock • Receive 10 ml of gross blood • Cell count:• Unevaluable abdominal – RBC > 100000 status – WBC > 500 – Alcohol / drug • Biochemistry: – Head / spinal injury – amylase > 175 iU/ml – unconscious • Microscopic: – food particle, bile, bacteria
  13. 13. DPL• False positive rate in RBC count 11%, esp. in low RBC cell count• False positive rate in WBC count: late DPL
  14. 14. Computer Tomography• Great sensitivity and specificity• Detect hollow viscus, retroperitoneal injury• Grading organ injury  non-operative management plan• Blunt VS penetrating
  15. 15. Limitation of CT scan• Some hollow viscus and mesenteric injury• Patient’s hemodynamic status
  16. 16. Type of injury• Blunt injury• Penetrating injury• Blast injury
  17. 17. Algorithm for the management of blunt abdominal trauma Blunt abdominal trauma Clinically Clinically evaluable unevaluable Diffuse No diffuse Hemodynamic abdominal abdominal stable tenderness tenderness Hemodynamic Hemodynamic OR CT + CT - stable labile OR or NOMx observation
  18. 18. Hemodynamically labileFAST + FAST - Other causes or No other causes or OR hemodynamically hemodynamically labile present labile present Further evaluation/ DPA + DPA - resuscitation Further OR evaluation/ resuscitation
  19. 19. Hemodynamically stable FAST + FAST - CT? CT + CT - observationOR / NOMx observation
  20. 20. Algorithm for the management of penetrating abdominal trauma Penetrating abdominal trauma Diffuse Diffuse abdominal abdominal tenderness + tenderness - Hemodynamically Hemodynamically OR stable labile
  21. 21. Hemodynamically stableLeft thoracoabdominal No left or right anterior thoracoabdominal thoracoabdominal injury injury laparoscopy GSW SW OR? observation
  22. 22. Hemodynamically labile Other cause of No other cause of hemodynamically hemodynamic lability present labilityDPA + DPA - OR OR Further evaluate/ resuscitate
  23. 23. Investigation for penetrating injury with hemodynamic stableLocation investigationThoracoabdomen CT scan thoracoscopy laparoscopyAnterior abdominal wall LWE FAST, DPL CTBack and flank CT
  24. 24. Options of evaluation in penetrating injury Investigation % Sensitivity % SpecificityPhysical Examination 95-97 100Local Wound 71 77ExplorationDPL 87-100 52-89FAST 46-85 48-95CT scan 97 98
  25. 25. Blast Injury Primary Secondary Tertiary QuaternaryBlast wave Shrapnel Blast wind Other consequences
  26. 26. Indication for surgery• Hemodynamic unstability• Peritonitis• Inability to• examine patient
  27. 27. Non-operative treatment• Solid organ injury only• Hemodynamically stable• No peritonitis• Capable for serial examination immediate investigation and celiotomy if needed• Multiple / combined injury
  28. 28. Missed abdominal trauma• Intraabdominal organs – Diaphragmatic injury – Hollow viscus injury – Retroperitoneal injury – Mesenteric injury• Other combined injury
  29. 29. Combined injuriesHead and abdominal injuries 5.7%Challenges:• Reliability for abdominal evaluation• Timing of CT evaluation of the head• Severe head trauma in non-operative Mx of abdominal solid organ injury• Major intraabdominal injury with severe blood loss leads secondary brain injury
  30. 30. Algorhitm for the management of combined head / abdominal trauma Combined head and abdominal injury Hemodynamically Hemodynamically stable labile GCS < 12 GCS > 12 GCS < 9 GCS > 9 Localizing sign No localizing sign Localizing sign No localizing sign CT before Laparotomy Laparotomy Laparotomy laparotomy before CT Then BH / ICP Follow by CY scan Post op CT scan
  31. 31. Pelvic fracture
  32. 32. Pelvic Fractures Mechanism• AP compression• Lateral compression• Vertical shear
  33. 33. Pelvic FracturesAssessment• Inspection: Leg-length discrepancy, external rotation• Pelvic ring: Pain on palpation of bony pelvic ring• Palpate prostate• Associated injuries• Pelvic bleeding
  34. 34. Pelvic FracturesEmergency Management • Fluid resuscitation • Determine if open or closed fracture • Determine associated perineal /GU injuries • Determine need for transfer • Splint pelvic fracture
  35. 35. Splinting fractured pelvis• Pelvic wrapping• Pelvic C-clamp• External fixator• ORIF
  36. 36. Special considerations
  37. 37. Case I: 32 year-old female• GA 37 weeks• G2P1001• Patient model for medical student• On the way home: MCA• Pain on movement both hip joints
  38. 38. Pelvic wrappingRoll on her left side
  39. 39. External fixator
  40. 40. Case II: 37 year-old male• Short gun wound abdomen• Unstable vital signs on arrival
  41. 41. Case III: 48 year-old male• gunshot wound ? At posterior right tight• Unstable vital signs on arrival• No abdominal sign on arrival
  42. 42. ConclusionATLS initial assessment• Primary survey• Adjunct to primary surveySelect appropriate investigation(s) for the injury