How to diagnose the disease

1. PONGSASIT SINGHATAS, M.D.
Department of Surgery
Faculty of Medicine, Ramathibodi Hospital
Mahidol University

2. Patient survive
Low morbidity
GOOD JUDGMENT COMES FROM
EXPERIENCE
EXPERIENCE COMES FROM
BAD JUDGMENT

3. Airway and Breathing first
Solid organ and Vascular injury => C
Hollow viscous injury => Sepsis

4. Investigate and assessment of abdomen base
on three group
1)Normal abdomen
2)Equivocal require investigation
3)Obvious abdominal injury
Diagnosis modalities
1) PE
2) DPL
3) FAST
4) CT scan
5) Diagnostic laparoscope

6. Hemodynamically normal patient
Full evaluation and decision to surgery or
non-operative management
Hemodynamically stable patient
Will benefit from investigation aimed to
- Patient bled into abdomen ?
- Bleeding has stopped ?
- Hollow viscous injury ?

7. Hemodynamically unstable patient
Try to define bleeding is taking place e.g. pelvis
or abdominal cavity
FAST quicker than DPL but operator dependence
Negative DPL => very clear that the intra
abdominal bleeding is unlikely in unstable
patient

9. Negative Exporation => Survive
Positive Unexploration => Dead
 เจ็บฟรี, เสียหน้า, เสียเวลา
 Operative complication (GA, wound, adhesion)
 Communication with patient and relative
Except Negative Exploration in Pelvic Fx

10. Unstable vital sign with
abdominal cause
or
Peritonitis
(Diffuse Abdominal tender)

11.  Bowel content
 Bile
 Urine
 Pancreatic juice
 Blood
Difficult to exam in
Head injury
Cord injury
Intoxication

12. Adequate analgesia
 Never mask abdominal symptom
 Make abdominal pathology easier to assess
- Clear physical sign
- Co-operative patient

14. FAST in unstable patient
 Positive => explore laparotomy
 Equivocal => DPL/DPA or explore laparotomy
 Negative => Find other bleeding, if not found
DPL/DPA or explore laparotomy
 No ultrasound available =>DPL/DPA
Not sent unstable patient to CT room
Abdominal sign
 Pelvic fracture with lower abdominal sign

16.  CT or FAST not available
 No other source in hemodynamic unstable
 Distinguish blood from other type of fluid
DPA => gross blood in unstable patient
Trauma Mattox Edition6

17.  Not BP only
 Hypertensive patient ??
 Sign of poor tissue perfusion
4 classification of hypovolemic shock
And
Responsibility after fluid resuscitation

18. Class I Class II Class III Class IV
For 70 kg male

19. 2000 mLof isotonic solution in adult; 20 mL/Kg in children

20.  Solid organ injury => liver, spleen, kidney,
pancreas
 Vascular injury with interventionist
 Need ICU
 Need OR available
 Need Surgeon available
 Necessary to CT scan ??

21. - Triple contrast
- Solid parenchymal organ injury
- Free air (Plain film abdomen)
- Free fluid with Hounsfield Units
- Contrast extravasations (lumen and vessel)
- Injury grading
Limitation
- Hollow viscus
- Mesenteric injury
- Diaphragmatic injury
- Bladder injury (need CT cystogram)

23. Trauma Mattox Edition6

24. Unstable Stable
FAST Positive EL CT
FAST Equivocal DPA +/- EL CT
FAST Negative Find other
bleeding, if not
found DPA +/- EL
Repeat FAST
Observe
CT ??
CT not available
???

27.  Not routinely
 Stab wound
 Anterior abdomen
 No indication in Flank or back
 Under local anesthesia
 Positive => Penetration of posterior fascia
Rarely practice in trauma center
Trauma Mattox Edition6

29. Serial PE
 Observe 24 hr
 Ideal same surgeon
 Frequent check V/S
 Abdominal sigh every
4 hr
 Persist local
symptom => other
modality evaluated
DPL
 Unstable with other
cause bleeding
 Stable R/O hollow
viscus or
diaphragmatic
injury
FAST
 Not recomment

30. Routine laparotomy both stab and
GSW
Increase conservative in stab wound
Laparotomy in GSW
More conservative in GSW

31.  Not routine in
anterior stab
wound
 Recommend in
- Stab wound at
flank and back (15%
require surgical repair)
- GSW
 Triple contrast
 Wound tract
evaluated
 Free air, free fluid
 Contrast
extravasate
 Intraluminal
contrast leak
 Bowel wall defect

32. Trauma Mattox Edition6

33.  Peritonitis
 Unstable vital sign
 Blood replacement??

34.  Most common cause in trauma
 Presumed hemorrhagic shock until proven
otherwise
 Fluid resuscitation in early signs and
symptoms of blood loss
Principle is Stop the bleeding
and replace the volume loss

35.  Whole blood is superior than component
therapy
 PRBC:FFP ratio of 1:1 or 2:1
 Platelet require in blood loss greater than
1.5 blood volume

36. อุดรูรั่วและเติมน้าให้ทัน
ถ้าตุ่มแห้ง => เลือดหมดตัว => ตาย
Exsanguination = Extensive Hemorrhage

37. - Large syringe connect to pressure source
(human hand)
- IV pressure bag
- Pneumatic external pressurized
intravenous infusion system
Increasing hematocrit and decreasing
temperature => Increase blood viscosity

38.  Controlled resuscitation, balance
resuscitation, permissive hypotension
 Keep SBP 80-90 mmHg or 100 mmHg if
head injury is suspected
 Penetrating trauma with hemorrhage
 No evidence in blunt trauma
Manual of Definitive Surgical
Trauma Care, Boffard

39. Delay aggressive fluid resuscitation
until definitive control
Prevent additional bleeding
Balance of organ perfusion
and
Risk of rebleeding
(accept a low normal blood pressure)
Manual of Definitive Surgical
Trauma Care, Boffard

41.  Desire to reassess the intra-abdominal content
(directed re-look)
 Evidence of decline of physiology reverse
1)Initial body temperature < 34 C
2)Initial acid-base status
- Arterial pH <7.2
- Serum lactate > 5 mmol/L
- Base deficit <-15 mmol/L in patient <55 years
or <-6 mmol/L in patient >55 years
Manual of Definitive Surgical
Trauma Care, Boffard

42. 3)Onset coagulopathy
PT >16 sec or PTT >60 sec
>50% of normal
4)Other condition
- >10 unit blood
- SBP <90 mmHg more than 60 min
- Operating time >60 min
Control
1. Bleeding
2. Contamination

44.  Thoracotomy if indication
 Laparotomy if indication
 In unstable patient, what is first?
=> depend on ICD content
=> prep both chest and abdomen

46. Diaphragmatic injury
 Difficult to diagnosis
 Both hemothorax and hemoperitonem in one
penetrate wound
 Bowel content or NG tube at chest (Lt) from
film chest in blunt
 Should be repair by non absorbable
 Laparoscopic diagnosis and repair is
standard
 Can repair from thoracotomy or laparotomy

47.  11 in 28 (39%) mortality in unstable pelvic Fx
with laporotomy
 FAST positive => retroperitoneal hematoma
passes into abdominal cavity
 31 in 80 unstable pelvic Fx patients with free
fluid and undervent laparotomy
 1 in 31 patient show retroperitoneal
hemaotoma alone
 Mortality rate 35% in laparotomy group
J.K. Bryceland, Injury, Int. J. Care Injured 2008
Steffen R, J Trauma.2004;57:278 –286.

48. Trauma Mattox Edition6
Unstable

49. Secondary brain injury
- Hypovolemic shock
- Polycompartment syndrome
Severe HI associated DIC
- Now, conservative in solid organ injury is
accept
- Threshold for laparotomy lower than non HI
Laparotomy or CT head first ??
Laparotomy in patient with GCS 2T ??
Trauma Mattox Edition6

50. Trauma Mattox Edition6

53. Technique for temporary
control of hemorrhage
Perihepatic packing
Electrocautery or argon beam
coagulator
Pringle’s manoeuvre
Hemostatis agent and glues
Hepatic suture -> large curve needle
Chromic

54. Technique for temporary
control of hemorrhage
Finger fracture hepatotomy and
vessel ligation
Tract temponade balloon
(Sengstaken tube)
Tractotomy and direct suture
Mesh wrap
Hepatic artery ligation

55. Technique for temporary
control of hemorrhage
Hepatic resection
Hepatic vascular isolation
Atriocaval shunt
Veno-venous bypass

56. Hepatic vascular isolation
 Pringle’s manoeuvre
 Clamp IVC above Rt kidney (Suprarenal)
 Clamp IVC above live (Suprahepatic)

57. Atriocaval shunt

61.  Good exposure
 Proximal and distal control
 Anatomical distortion from hematoma
 Active bleeding
- Pressure first
- Supraceliac control or Lt anterolateral
thoracotomy in aorta injury
- Supradiaphragmatic control in IVC
Manual of Definitive Surgical
Trauma Care, Boffard

63.  Retroperitoneal organ
 In early of injury, abdominal exam is difficult
 FAST or DPL maybe negative
 Retorperitoneal free air in plain film
or CT)
 High mortality if delay diagnosis
 Should be Kocherization and open lesser sac
in blunt abdominal injury

64. Trauma Mattox Edition6
Duodenal Inj

65. Trauma Mattox Edition6
Pancreatic Inj

67. Non-operative
Indication for surgery follow non-operative
 Hemodynamic instable
 Evidence of continued splenic hemorrhage
 Associate intra-abdominal injury requiring
surgery
 Replacement of more than 50% of blood
volume

68. Spleen not active bleeding
-> left alone
Splenic surface bleeding only
-> packing, diathemy or fibril glue
Minor lacerations
-> absorbable suture use pledget,
omental patch may be place

69. Splenic tears
1) Mesh wrap -> absorbable mesh e.g. Vicryl
wrap from hilum and around parenchyma
2) Partial splenectomy -> ligating segmental
vessel at hilum and seen demarcation
ischemic pole
3) Splenectomy

70. Option
 Primary repair
 Resection
+/- anastomosis
+/- proximal
diversion
 Diversion only
Depend on
 Position of injury
=> Stomach, Small
bowel, Colon
 Severity of injury
 Contamination
 Patient status
Can not conservative
Need to Laparotomy

72.  Aim of trauma is patient survive
 Different resource => different judgment
 Now, try conservative but patient safety is
most important
 Don’t forget call for help
 Damage control if indication