A case presentation on blunt trauma abdomen

1. Welcome to
Clinical Case Presentation

2. A 18 years old Boy With
blunt Trauma abdomen
following RTA
Presented by
Dr. Md. Masud Rana
Honorary Medical Officer
Casualty Block I
Dhaka Medical College Hospital

3. Particulars of the patients :
 Name : Ismail
 Age : 18 years
 Sex : Male
 Religion : Islam
 Occupation : Truck Helper
 Address : Fulpur, Mymensing
 Date & time of admission : 21/12/2023 at 3:00 am
 Date & time of examination : 21/12/2023 at 3:15 am

4. Presenting complaints :
*Severe Abdominal pain following RTA occurred one & half hours back.

5. MIST
• M-Mechanism of injury: Road Traffic Accident
• I-Injuries found: There was no visible external injuries
• S-symptom & sign: Pulse-130 bpm, BP-80/60 mmHg
Abdomen: soft but very tender
• T-Treatment initiated: Patient was directly taken to DMCH

7. Primary survey
C = There was no exsanguinating external haemorrhage
A (Airway with cervical spine protection):
• Airway : Intact
• Cervical spine : Protected
B ( Breathing and ventilation):
• Respiratory rate : 28 breaths/min
• SpO2 :90% with 8L of O2 supplementation
• Breath sound : Vesicular on both sides
• No restriction of movement with respiration

8. Primary survey(cont.)
C(Circulation with haemorrhage control)
 Pulse : 130 beats/min
 Blood pressure : 80/60 mmHg
 Anemia : (++)
 Capillary refilling time : >2sec
D(Disability and neurological status)
 GCS :15/15
 Pupil : Normal in size and shape, reacting to light

9. Primary survey(cont.)
• E= Patient was Exposed under controlled environment

10. Adjuncts to primary survey
Blood was sent for –
 Blood grouping, Rh typing, cross-matching & screening.
 CBC
 RBS
 S. Creatinine
 S. Electrolytes

11. Immediate management :
 High flow (8L/min) O2 inhalation.
 Opening of 2 wide bore I/V channels.
 Fluid resuscitation by I/V crystalloid fluid. (Hartmann’s solution)
 NG tube insertion for continuous suction(undigested food particles
with clotted blood was found)
 Per-Urethral catheterization was done and 60 ml of high colored urine
came out
 Administration of Analgesic(NSAIDs) and anti-ulcerant(inj-
omeprazole 40mg).
 Blood Transfusion

12. Immediate management(cont.)
• Post resuscitation F/U:
subjective: severe abdominal pain
objective: pulse: 100bpm
BP: 100/70mmHg
Temp: cold & calm periphery
R/R-20 breaths/min
Anaemia: ++
GCS: 15/15, pt is agitated
Per abdomen: soft but severe tender,
bowel sound present but very sluggish
Urine output: Scanty high color urine(30 ml)
NG tube collection: 50ml undigested food particle with blood clot

13. Immediate management(cont.)
• Assessment: vitals are becoming near normal
• Plan: * continue resuscitation
*continue F/U at 30 min interval
During resuscitation and giving F/U at 30 mins interval we found that
Our patient’s vitals were becoming near normal but that was not
persistent and his vitals were going to pre-resuscitation state that
indicates that ,he was a “Transient Responder”
We plan to prepare this patient for “ Damage control surgery”

14. Radiological investigations & Imaging
 Plain X-ray Cervical spine A/P & lateral view
 Plain X-ray Chest A/P view
 Plain X-ray Pelvis A/P view
 Ultrasonography of whole Abdomen

15. Secondary Survey

16. Secondary Survey
AMPLE History
 Allergy : No known history of allergy to any food or drug.
 Medication : Was not taking any medication.
 Past illness : No history of any significant past illness.
 Last meal : Half an hour before event.

17. Secondary Survey (cont.)
 Event :
At Tongi, Gazipur sadar at 1.30 am on 21st December,2023 he was
unloading goods from truck at his working place. All on a sudden he
noticed that another truck was coming towards him facing the back of
that vehicle. He tried to scape but failed and get pressed in between two
trucks on his abdomen. He shouted and his coworkers rescued him.
They informed his family members and brought him to DMCH for
management.

18. Secondary Survey (cont.)
Head to toe examination
 Head, Face, Neck & Chest:
 No evidence of any penetrating injuries, swelling, tenderness,
bruising or any external bleeding and difficulties on movement.
 Abdomen:
 Abdomen was soft but severely tender
 Movement of abdomen with respiration was restricted
 Bowel sound: present but sluggish

19. Secondary Survey (cont.)
• External genitalia exam: nothing significant
• On DRE: nothing significant
 Other system examination:
 Revealed no abnormalities.

20. Salient feature
Ismail, age-18 years old hailing from fulpur, Mymensing admitted in
DMCH on 21/12/23 at 3:00am with blunt trauma over the upper
abdomen due to RTA occurred 1.5 hours back , On primary survey,
patient’s airway was clear, respiratory rate was 22 breaths/min, SPO2 –
90% with 5liter of oxygen supplementation, pulse rate- 130 beats/min,
blood pressure -80/60 mmHg , he was moderately anaemic(++), GCS-
15/15, urine output was 60ml after catheterization that was high colored.
There was no focal neurological deficit . Patient was examined under
controlled environment .

21. Salient feature(cont.)
2 wide bore cannulation were done and crystalloid was administered.
Blood was withdrawn and sent for blood grouping , Rh typing, cross-
matching & screening and for some routine investigations. Pt party
was advised to manage 6 units of fresh whole Blood according to
grouping & Rh typing. NG tube was inserted and suction was started,
content was undigested food particles mixed with clotted blood. Our
patient was transient responder according to “Dynamic Fluid
Response”

22. Salient feature(cont.)
* On secondary survey , there were no evidence of penetrating
injuries, swelling, tenderness, bruising or any external bleeding and
no difficulties on movement were found on head, neck, face and
chest.
* On Abdominal examination there was no visible external injury ,
abdomen was soft but severe tender, bowel sound was present but
Sluggish. External genitalia exam. and DRE findings were normal.
Other system revealed no abnormalities.

23. Provisional Diagnosis

24. Gastric perforation due to
Blunt trauma abdomen
following RTA with
hemorrhagic Shock

25. Consent
After proper counseling and describing about all risks benefits of
treatment options and post-operative complications, patient’s legal
guardian gave consent for Surgery

26. Operation note
 Date : 21st December, 2023
 Time : From 9.00 am to 1.00pm.
 Venue : Casualty OT.
 Indication : Blunt trauma abdomen following RTA with shock
 Name of operation: Laparotomy followed by splenectomy with distal
pancreatectomy(body & tail) with primary repair of gastric perforation
at lesser curvature near antrum.
 Nature of anesthesia: General
 Incision: Midline incision

27. Operation note(cont.)
 Findings:
1. Approximately 2L of blood in the peritoneal cavity
2. Serosal tear over the anterior surface of body of stomach measuring
about 3cm*3cm. A perforation in the lesser curvature near antrum about
3cm*3cm.
3. Splenic vessels with pancreas( left lateral to neck) were transected .

28. Operation note(cont.)
• Procedure:
* with all available aseptic precaution abdomen was opened by midline
Incision , a large hematoma and free blood found in peritoneal cavity .
*Vascular control(splenic vessels) was achieved.
* Splenectomy with distal Pancreatectomy(left lateral to neck) was
done.
* Perforation and serosal tear of stomach was repaired

29. Here we can see
the resected distal
part of pancreas (
body and tail) along
with the splenic
vessels and Spleen

30. Transected
Pancreas at Body
and ligated
splenic vessel

31. Specimen:
Resected Distal
pancreas(body &
tail) with Spleen

32. Operation note(cont.)
* After thorough peritoneal toileting abdomen was closed in layer.
* 3 drain tubes were kept in situ . One in hepato-renal pouch, one in
stomach bed and last one in pelvis
* 5 units of whole blood and 1unit FFP were transfused per
operatively.
* Patient was haemo-dynamically stable during the procedure.
* Recovery from anesthesia was delayed so ETT was kept in situ
and pt was shifted to HDU

33. Post operative managements:
 Treatment order:
 Nothing per oral-TFO.
 O2 inhalation 2-3l/min stat and sos
 inf 5% DA 2000 ml + inf 5% DNS 500 ml -I/V @ 25 drops/min
 Inj. Meropenem(1gm)- I/V 8 hourly.
 Inj. Metronidazole(500mg)- I/V 8 hourly.
 Inj. Omeprazole(40mg)- I/V 12 hourly
 Inj. Pethidine(75mg)- I/M 12 hourly.
 Inj. Ondansetran (8mg)-I/V 8 hourly

34. Post operative managements(cont.)
 Treatment order:
*Inj. Traxyl(500mg)-1 amp I/V 8hourly
*Inj. Nor-Ad 2amp+ 50ml NS I/V @2-20ml/hour by infusion pump
 Advice:
*Early ambulation of the patient
*Maintain intake-output chart routinely
*Maintain CBG chart 8 hourly
*Monitor all vital signs and record it

35. Post Operative Follow-up
Points
Subjective
1st POD
1.Pain in the operative area
3nd POD
1. Nothing significant
except pain in the
operative area
5th POD
1. Nothing significant
except pain in the
operative area
Objective *Pulse: 97bpm
*BP:115/70 mmHg(inotrop support)
*Temp: Normal
*R/R: 18 bpm
*Anaemia: +
*Dehydration: +/-
*Heart: S1+S2
*Lungs: clear
*SpO2: 100% (intubated)
*Pulse: 112bpm
*BP:110/70 mmHg
*Temp: Normal
*R/R: 20 bpm
*Anaemia: +
*Dehydration: (-)
*Heart: S1+S2
*Lungs: clear
*SpO2: 96% with 5l O2
*Pulse: 120bpm
*BP:90/70 mmHg
*Temp: raised , 101 f
*R/R: 18 bpm
*Anaemia: +/-
*Dehydration: (-)
*Heart: S1+S2
*Lungs: clear
*SpO2: 99% without O2
*Abdomen: Tense & tender
*B/S: Absent
*DT Collection:
D1(subheap): 300ml
D2(stomach bed): 350ml
D3(pelvic): 270ml
*NG tube collection: 70ml
*Urine OP:250ml in last 3 hrs
*GCS: E4 Vt M6
*Dressing: Dry
*Abdomen: Tense & tender
*B/S: Absent but bowel moved
*DT Collection:
D1(subheap): 25ml
D2(stomach bed): 100ml
D3(pelvic): 110ml
*NG Tube collection:80 ml
*urine OP:50ml in last 2 hrs
*GCS: 15/15
*Dressing: Dry
*Abdomen: soft
*B/S: Present
*DT Collection:
D1(subheap): 50ml
D2(stomach bed): 70ml
D3(pelvic): 100ml
*NG tube collection: 100 ml bile
stained
*urine OP: 70 ml in last 2 hrs
*GCS: 15/15
*Dressing: Dry

36. Post Operative Follow-up(cont.)
Point 1st POD 3rd POD 5th POD
Assessment Pt is stable with initropic
support with
Endotracheal intubation
Pt is stable without
inotrop support
Pt condition is improving
Plan *Continue Rx
*Close monitoring of
patient
*Continue Rx
*Do routine investigations
*Close monitoring of
patient
*Continue Rx

37. Investigation
Name of investigation 23/12/23 Management 28/12/23 Management
CBC with ESR Hb%-10.2gm/dl
TC-26,950/cu mm
DC-N-94.3%
L-3.5%
PLT-1,26,000/cu mm
Hb%-13 gm/dl
TC -18,000/cu mm
DC –N- 79%
L –13%
PLT- 1,45.000/cu mm
S. Creatinine
S. Amylase
S. Lipase
S. Albumin
S. Total Ca2+
RBS
1.39 mg/dl
114 U/L
66 U/L
2 gm/dl
6.7 mg/dl
5.6 mmol/l
•Inj. Calcium gluconate
(10 ml)
--- 10 ml+ 10 ml D/W
then give I/V over 10-20
mins
• Inj. Albutein infusion
for 3 days
0.9 mg/dl
41.6 U/L
65 U/L
2.9gm/dl
7.8mg/dl
3.6mmol/L
• Egg white
• Inj. Albutein
infusion
•Inj. Calcium gluconate
(10 ml)
--- 10 ml+ 10 ml D/W
then give I/V over 10-20
mins
Serum Electrolytes Na+-136 mmol/l
k+ -4.8 mmol/l
Cl – 105 mmol/l
Na+-147mmol/l
K+ -3.1 mmol/l
Cl -104 mmol/l
• Syp. KT 2tsf –TDS