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01.abdominal trauma.cpirozzi
- 1. Abdominal Trauma Dr. Mohammad Ibrahim
- 2. Abdominal Trauma • Penetrating Abdominal Trauma – Stabbing 3x more common than firearm wounds – Most commonly injured organs: small intestine > colon > liver • Blunt Abdominal Trauma – Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/systems) – Most commonly injured organs: spleen > liver, intestine is the most likely hollow viscus Rosen’s Emergency Medicine, 7th ed. 2009
- 3. Pathophysiology of injury Penetrating Abdominal Trauma • Stab Wounds – Knives, ice picks, pens, coat hangers, broken bottles – Liver, small bowel, spleen • Gunshot wounds – small bowel, colon and liver – Often multiple organ injuries, bowel perforations Rosen’s Emergency Medicine, 7th ed. 2009
- 4. Pathophysiology of injury Rosen’s Emergency Medicine, 7th ed. 2009
- 5. Pathophysiology of injury Blunt Abdominal Trauma • Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures • Crushing effect • Acceleration and deceleration forces → shear injury • Seat belt injuries – “seat belt sign” = highly correlated with intraperitoneal injury Rosen’s Emergency Medicine, 7th ed. 2009
- 6. Physical Exam • Generally unreliable due to e.g.: spinal cord injury • Look for signs of intraperitoneal injury – abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension – entrance and exit wounds to determine path of injury. – Distention - pneumoperitoneum, gastric dilation, or ileus – Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhage – Abdominal contusions – ↓bowel sounds suggests intraperitoneal injuries – DRE: blood Rosen’s Emergency Medicine, 7th ed. 2009
- 7. Diagnostic studies • Lab tests: not very helpful • May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox screen Rosen’s Emergency Medicine, 7th ed. 2009
- 8. Imaging • Plain films: – fractures – nearby visceral damage – free intraperitoneal air – Foreign bodies and missiles Rosen’s Emergency Medicine, 7th ed. 2009
- 9. Imaging • CT – Accurate for solid visceral lesions and intraperitoneal hemorrhage – guide nonoperative management of solid organ damage – IV not oral contrast Rosen’s Emergency Medicine, 7th ed. 2009
- 10. Imaging • Angiography – To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable pt – Rarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma Rosen’s Emergency Medicine, 7th ed. 2009
- 11. FAST • Focused assessment with sonography for trauma (FAST) – To diagnose free intraperitoneal blood after blunt trauma – 4 areas: • Perihepatic & hepato-renal space (Morrison’s pouch) • Perisplenic • Pelvis (Pouch of Douglas/rectovesical pouch) • Pericardium (subxiphoid) – sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid • Extended FAST (E-FAST): – Add thoracic windows to look for pneumothorax. – Sensitivity 59%, specificity up to 99% for PTX Trauma.orgRosen’s Emergency Medicine, 7th ed. 2009
- 12. FAST • Morrison’s pouch (hepato-renal space) trauma.org Rosen’s Emergency Medicine, 7th ed. 2009
- 13. FAST • Perisplenic view trauma.org Rosen’s Emergency Medicine, 7th ed. 2009
- 14. FAST • Retrovesicle (Pouch of Douglas) • Pericardium (subxiphoid) trauma.orgRosen’s Emergency Medicine, 7th ed. 2009
- 15. FAST • Advantages: – Portable, fast (<5 min), – No radiation or contrast – Less expensive • Disadvantages – Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. – Limited by obesity, substantial bowel gas, and subcut air. – Can’t distinguish blood from ascites. – high (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture Rosen’s Emergency Medicine, 7th ed. 2009
- 16. Diagnostic Peritoneal Lavage • Largely replaced by FAST and CT • In blunt trauma, used to triage pt who is HD unstable and has multiple injuries with an equivocal FAST examination • In stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injury Rosen’s Emergency Medicine, 7th ed. 2009
- 17. Diagnostic Peritoneal Lavage • 1. attempt to aspirate free peritoneal blood – >10 mL positive for intraperitoneal injury • 2. insert lavage catheter by seldinger, semiopen, or open • 3. lavage peritoneal cavity with saline • Positive test: – In blunt trauma, or stab wound : RBC count > 100,000/mm3 Rosen’s Emergency Medicine, 7th ed. 2009
- 18. Local Wound Exploration • To determine the depth of penetration in stab wounds • If peritoneum is violated, must do more diagnostics • Preop, extend wound, carefully examine (No blind probing) • Indicated for anterior abdominal stab wounds, less clear for other areas Rosen’s Emergency Medicine, 7th ed. 2009
- 19. Laparoscopy • Most useful to eval penetrating wounds to thoracoabdominal region in stable pt – esp for diaphragm injury: Sens 87.5%, specificity 100% • Can repair organs via the laparoscope – diaphragm, solid viscera, stomach, small bowel. • Disadvantages: – poor sensitivity for hollow visceral injury, retroperitoneum – Complications from trocar misplacement. – If diaphragm injury, PTX during insufflation Rosen’s Emergency Medicine, 7th ed. 2009
- 20. Management • General trauma principles: – airway management, 2 large bore IVs, cover penetrating wounds and eviscerations with sterile dressings • Prophylactic antibiotics: decrease risk of intra- abdominal sepsis due to intestinal perf/spillage – (eg zosyn 3.375 g IV) • In general, leave foreign bodies in and remove in the OR Rosen’s Emergency Medicine, 7th ed. 2009
- 21. Management of penetrating abdominal trauma forsurenot.com
- 22. Management of penetrating abdominal trauma • Mandatory laparotomy vs • Selective nonoperative management Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
- 23. Management of penetrating abdominal trauma • Mandatory laparotomy – standard of care for abdominal stab wounds until 1960s, for GSWs until recently – Now thought unnecessary in 70% of abdominal stab wounds – Increased complication rates, length of stay, costs – Immediate laparotomy indicated for shock, evisceration, and peritonitis Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
- 24. Management of penetrating abdominal trauma • Selective management used to reduce unnecessary laparotomies • Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair • Strategy depends on abdominal region: – Thoracoabdomen • Nipple line to costal margin – Anterior abdomen • Xiphoid to pubis – Flank and back • Posterior to anterior axillary line Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
- 25. Management of Blunt abdominal trauma ashwinearl.blogspot.com
- 26. Management of Blunt abdominal trauma • Exam less reliable • Diagnostic studies to determine if there is hemoperitoneum or organ injury requiring surgical repair – FAST, CT, DPL – In HD stable pts, CT is preferred Rosen’s Emergency Medicine, 7th ed. 2009
- 27. Management of Blunt abdominal trauma • Clinical Indications for Laparotomy after Blunt Trauma MANIFESTATION PITFALL Unstable vital signs with strongly indicated abdominal injury Alternative sources, shock Unequivocal peritoneal irritation Unreliable Pneumoperitoneum Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy) Evidence of diaphragmatic injury Nonspecific Significant gastrointestinal bleeding Uncommon, unknown accuracy Rosen’s Emergency Medicine, 7th ed. 2009
- 28. Damage Control • Patients with major exsanguinating injuries may not survive complex procedures • Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
- 29. Damage Control • 0. initial resuscitation • 1. Control of hemorrhage and contamination – Control injured vasculature, bleeding solid organs – Abdominal packing • 2. back to the ICU for resuscitation – Correction of hypothermia, acidosis, coagulopathy • 3. Definitive repair of injuries • 4. Definitive closure of the abdomen Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
- 30. Damage Control Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
- 31. Damage Control Resuscitation in the ICU • IVF (crystalloid, not colloid) • Transfusion -PRBC/plt/FFP • Recombinant activated factor VII – Increased thromboembolic complications • Rewarming if hypothermic • Correction of metabolic abnormalities • Low tidal volume ventilation recommended (4-6 ml/kg) Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
- 32. Damage Control Open abdominal wounds and definitive closure • 40-70% can’t have primary closure after definitive repair. • Temporary closure methods Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
- 33. Abdominal Compartment Syndrome • Common problem with abdominal trauma • Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure – ± APP below 50 mm Hg • Primary ACS: associated with injury/disease in abdomen • Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak) Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
- 34. Abdominal Compartment Syndrome Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29
- 35. Abdominal Compartment Syndrome • Effects of elevated IAP – Renal dysfunction – Decreased cardiac output – Increased airway pressures and decreased compliance – Visceral hypoperfusion Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
- 36. Abdominal Compartment Syndrome • Management – Surgical abdominal decompression – Nonsurgical: paracentesis, NGT, sedation – Staged approach to abdominal repair – Temporary abdominal closure Sugrue M. Curr Opin Crit Care 2005; 11:333-338Bailey J. Crit Care 2000, 4:23–29
- 37. -A 22 Ys old male presented to our ER by paramedics after motor bicycle crash into a tree to the Lt. side of his trunk. At time of trauma his BP was 100/70 , pulse 114 /min., RR 18/ min., GLCS 14 as regard to paramedics report. In ER he became drowsy and start deteriorating. In ER his BP was 60/45 , pulse 135 /min., RR 32/ min., GLCS 11. 1ry survey reveals intact airway, tenderness over the lower part of Lt. side of chest wall with diminished breath sounds on the Lt. side, abdominal tenderness and rigidity on the Lt. hypochondrium. After resuscitation Chest X ray revealed fractures last Lt. 3 ribs and haemothorax. Abdominal U/S revealed haematoma surrounding the spleen and free blood in the abdomen.
Editor's Notes
- Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
- Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
- Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures created by outward forces Lap-belt restraints “seat belt sign” = contusion or abrasion across the lower abdomen, highly correlated with intraperitoneal injury
- eg lap belts herald abdominal injuries in one third of cases
- films in which the patient is in a lateral decubitus position, air is located in the superior flank and outlines the lateral liver edge Demonstration of free intraperitoneal air on left lateral decubitus film. This is the preferred decubitus position because it avoids confusion with the gastric bubble and splenic flexure Erect film demonstrates the soap bubble appearance of retroperitoneal air outlining the right kidney. Duodenal perforation is the responsible pathologic condition
- Grade 4 splenic laceration Grade 3 right renal laceration (encircled). CT is particularly helpful in guiding nonoperative management of solid organ damage.[44-46] This includes as-needed follow-up studies of convalescing patients with these injuries. It has also proven effective when incorporated in delayed fashion for patients with decreasing hematocrit, increasing base deficit, or subtle examination changes. By minimizing the incidence of nontherapeutic laparotomies for self-limited injury to the liver or spleen, trauma centers are using CT with intravenous (IV) contrast only, as it has been shown that little additional information is provided by the addition of oral contrast, which delays scanning and may pose an aspiration risk for the patient.[48,49]
- Angioembolization of splenic laceration. Note coil in the splenic artery (white arrow) and blush representing active hemorrhage stemming from two branches
- Dependent portions of the intraperiton when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agentseal cavity where blood is likely to accumulate
- Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
- Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
- Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
- Dependent portions of the intraperitoneal cavity where blood is likely to accumulate when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agents Newer studies advocate adding sonographic contrast to further delineate solid organ injuries with minimal hemoperitoneum, especially those of the spleen and liver, which might be amenable to nonoperative management.[64-66] Overall, US can serve as an accurate, rapid, and less expensive diagnostic screening tool than DPL or CT.[67-70]
- GSW Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds
- Positive test = specific for intraperitoneal injury With lower chest stab wounds, a positive RBC count of 5000 to 10,000/mm3 should be considered as evidence of diaphragmatic injury. Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds
- (many do not reach the peritoneum) If LWE indicates that the peritoneum is violated, further diagnostics are indicated. When the stab wound is documented to be superficial to the abdominal cavity, the patient can be safely discharged home after appropriate wound care.[85] Other areas: like back, flank, chest
- This is considered safest in the event that the implement is intravascular or in a highly vascularized organ.The accuracy of physical examination is limited in cases of blunt and penetrating trauma. It is rendered less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, mental retardation), and spinal cord injury. intestinal perf/spillage can occur afger blunt or PAT Cover anaerobes
- For more extensive abdominal trauma, a central concept is that of damage control
- When would you use the damage control strategy? Essentially if the pt is really sick
- These are all big topics, about general ICU management but management in the ICU involves: The best transfusion protocol is debated.. 11.2010 NEJM eval of off-label, prospective clinical trials -> increased arterial thromboembolic complications with rfvii Low tidal volume ventilation- extrapolation from ards studies Critical care med 2004 retrospective cohort study- found association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome
- The best transfusion protocol is debated.. Low tidal volume ventilation
- Major complication of abdominal trauma APP = MAP - IAP
- Can lead to significant reduced lung volumes, impaired gas exchange, high ventilatory pressures.