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Topic Review :
Penetrating abdominal Trauma
                    นำเสนอวันพุธที่ 28 มีนำคม 2555
                        จัดทำโดย Ext.สรวิศ บุญญฐี
Learning Topic



 Anatomy of      Mechanism of   Management
  abdomen           Injury
Anatomy of Abdomen
Anatomy of Abdomen                  External
                     Anterior                             Thoraco -
                                  Flank        Back
                     abdomen                              abdominal




                                     Internal
                                              Retro -
                     Thoracic   Peritoneal                 Pelvic
                                             peritoneal
                      cavity      cavity       space
                                                           cavity
Anatomy of Abdomen (External)
Anatomy of Abdomen (Internal)
Mechanism of Injury
• Compression         • Laceration / low
• Crushing              energy
• Shearing            • Kinetic energy /
• Deceleration          high energy
  (fixed organs)

Blunt                 Penetrating

Mechanism of Injury
Mechanism of Injury
 Stab wound
 • Minimal symptom : high negative explore.
 • Complication from surgery : 22 %
 • Selective management.

 Gunshot wound
 • Higher Risk for internal organ injury
 • Risk of visceral organ injury : 90%
 • Suggest to operate.
Mechanism of Injury
 Shotgun wound
 • Many small bullets
 • Severity depend on distance of victim from weapon.
 • Type I : Long range. ( > 7 yards )
   • Subcutaneous. No need for operation
 • Type II : Short range. ( 3-7 yards )
   • Need operation & suture. Mortality 20 %
 • Type III : Very short range. (< 3 yards )
   • Large defect , Need operation, Mortality rate 85-90 %
Management
Surgery without Investigation


                      Gun shot wound
                                          Peritonitis
                      (not tangential)
Penetrating injury
                     Penetrating wound
                                         Hypotension
                            with


                                         Evisceration
Penetrating abdominal trauma

                           Circulatory status        Unstable      OR
                                Stable
                           Surgical abdomen            Yes         OR
         Stab wound
                                No              Gunshot wound
Anterior abdomen       Flank or back
                                                      Tangential wound ?
Local explore wound            CT Scan
     +ve                                                  Yes           No
                 -ve          +ve         -ve
  DPL or                                                DPL or
     OR         Observe       OR         Observe       Dx Laparo        OR
Penetrating Thoracoabdominal Trauma
                                             Acute phase

                                             Resuscitate
                                            ATLS protocols


                                             Insert NG if no
                                            contraindications

                   Normal                           CXR                              Abnormal

Indications for             No indication for             Indications for                    No indication for
surgical intervention           surgical                  surgical intervention
present                                                                                          surgical
                              intervention                present                              intervention
(ie: Thoracotomy or                                       (ie: Thoracotomy or
Laparotomy)                                               Laparotomy)
                         Right side     Left side                                    Right side      Left side

      OR                                                         OR                               Laparoscopy
   Examine                Admit         Laparoscopy                               Consider CT
                         Observe             or               Examine              Observe             or
  diaphragm                                                  diaphragm                            thoracoscopy
                        Repeat CXR      thoracoscopy
Investigation


                Diagnostic peritoneal lavage


                  Diagnostic Laparoscope


                  Local Wound Exploration
Diagnostic peritoneal lavage
- performed after gastric and urinary bladder
decompression
- Aspirate the content from intraabdomen.
  If aspiration is negative : lavage.
      Put in isotonic solution
            Lactated Ringer’s solution or normal saline
            A liter in adult and 20 ml/kg in children
      Mixing of the lavage fluid.
Diagnostic peritoneal lavage
Criteria for Diagnostic from DPL
 At least 10 ml of gross blood
 RBC count at least 100,000 / mm3
 WBC count at least 500 / mm3
 Amylase > 19 IU/L
 ALP > 2 IU/L
 Bilirubin level > 0.01 mg/dL
 Food particle , fecal material , bile , bacteria
 Fluid come from NG , urinary catheter , ICD
Diagnostic peritoneal lavage
False positive :
• Bleeding from the lavage site
• Injury of the omentum or mesentery by lavage catheter
False negative :
• Faulty catheter placement
• Compartmentalization of the abdomen by adhesion
• Bleeding is slow and perform DPL too early
• Rupture diaphragm
Diagnostic Laparoscope

Useful in :
   Thoracoabdominal wounds.
   Tangential GSW
   Equivocal stabbed wound
Advantage : Direct examination of
             intraperitoneal structure
Local Wound Exploration

 Evaluation the depth of the wound.
 Determine whether they penetrate
  the peritoneum.
 Usually performed in the wound that located
  anterior to the anterior axillary line.
?   Question
Reference

• Schwartz's Principles of Surgery, 9th Edition, 2010
• Sabiston Textbook of Surgery, 17th Edition, 2004
• Tintinalli's Emergency Medicine, 7th Edition, 2011
• Rosen’s Emergency Medicine 7th Edition, 2010
• ATLS Advanced Trauma Life Support for Doctors 8th
  Edition, 2008
• Evaluation of Abdominal Trauma, American Collage of
  Surgeons, 2003
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Penetrating abdominal trauma management

  • 1. Topic Review : Penetrating abdominal Trauma นำเสนอวันพุธที่ 28 มีนำคม 2555 จัดทำโดย Ext.สรวิศ บุญญฐี
  • 2. Learning Topic Anatomy of Mechanism of Management abdomen Injury
  • 4. Anatomy of Abdomen External Anterior Thoraco - Flank Back abdomen abdominal Internal Retro - Thoracic Peritoneal Pelvic peritoneal cavity cavity space cavity
  • 5. Anatomy of Abdomen (External)
  • 6. Anatomy of Abdomen (Internal)
  • 8. • Compression • Laceration / low • Crushing energy • Shearing • Kinetic energy / • Deceleration high energy (fixed organs) Blunt Penetrating Mechanism of Injury
  • 9. Mechanism of Injury Stab wound • Minimal symptom : high negative explore. • Complication from surgery : 22 % • Selective management. Gunshot wound • Higher Risk for internal organ injury • Risk of visceral organ injury : 90% • Suggest to operate.
  • 10. Mechanism of Injury Shotgun wound • Many small bullets • Severity depend on distance of victim from weapon. • Type I : Long range. ( > 7 yards ) • Subcutaneous. No need for operation • Type II : Short range. ( 3-7 yards ) • Need operation & suture. Mortality 20 % • Type III : Very short range. (< 3 yards ) • Large defect , Need operation, Mortality rate 85-90 %
  • 12. Surgery without Investigation Gun shot wound Peritonitis (not tangential) Penetrating injury Penetrating wound Hypotension with Evisceration
  • 13. Penetrating abdominal trauma Circulatory status Unstable OR Stable Surgical abdomen Yes OR Stab wound No Gunshot wound Anterior abdomen Flank or back Tangential wound ? Local explore wound CT Scan +ve Yes No -ve +ve -ve DPL or DPL or OR Observe OR Observe Dx Laparo OR
  • 14. Penetrating Thoracoabdominal Trauma Acute phase Resuscitate ATLS protocols Insert NG if no contraindications Normal CXR Abnormal Indications for No indication for Indications for No indication for surgical intervention surgical surgical intervention present surgical intervention present intervention (ie: Thoracotomy or (ie: Thoracotomy or Laparotomy) Laparotomy) Right side Left side Right side Left side OR OR Laparoscopy Examine Admit Laparoscopy Consider CT Observe or Examine Observe or diaphragm diaphragm thoracoscopy Repeat CXR thoracoscopy
  • 15. Investigation Diagnostic peritoneal lavage Diagnostic Laparoscope Local Wound Exploration
  • 16. Diagnostic peritoneal lavage - performed after gastric and urinary bladder decompression - Aspirate the content from intraabdomen. If aspiration is negative : lavage. Put in isotonic solution Lactated Ringer’s solution or normal saline A liter in adult and 20 ml/kg in children Mixing of the lavage fluid.
  • 18. Criteria for Diagnostic from DPL At least 10 ml of gross blood RBC count at least 100,000 / mm3 WBC count at least 500 / mm3 Amylase > 19 IU/L ALP > 2 IU/L Bilirubin level > 0.01 mg/dL Food particle , fecal material , bile , bacteria Fluid come from NG , urinary catheter , ICD
  • 19. Diagnostic peritoneal lavage False positive : • Bleeding from the lavage site • Injury of the omentum or mesentery by lavage catheter False negative : • Faulty catheter placement • Compartmentalization of the abdomen by adhesion • Bleeding is slow and perform DPL too early • Rupture diaphragm
  • 20. Diagnostic Laparoscope Useful in : Thoracoabdominal wounds. Tangential GSW Equivocal stabbed wound Advantage : Direct examination of intraperitoneal structure
  • 21. Local Wound Exploration  Evaluation the depth of the wound.  Determine whether they penetrate the peritoneum.  Usually performed in the wound that located anterior to the anterior axillary line.
  • 22. ? Question
  • 23. Reference • Schwartz's Principles of Surgery, 9th Edition, 2010 • Sabiston Textbook of Surgery, 17th Edition, 2004 • Tintinalli's Emergency Medicine, 7th Edition, 2011 • Rosen’s Emergency Medicine 7th Edition, 2010 • ATLS Advanced Trauma Life Support for Doctors 8th Edition, 2008 • Evaluation of Abdominal Trauma, American Collage of Surgeons, 2003