The Americal Association for the Surgery of Trauma - guidelines for intestinal injury- grading and a brief description of duodenal injury and few Most common Questions

1. You may forget her, but she will never forget you
INTESTINE

2. AAST Grading of Bowel Injury
Evidence based FAQs
Dr Awaneesh Katiyar
Senior Resident
Trauma Surgery and Critical Care
AIIMS Rishikesh

3. Overview
• Introduction
• Mechanism and initial management
• Grading of bowel injury
• Duodenal injury -brief management
• Topic of Discussion - related articles

4. Introduction
• 11% - blunt abdominal trauma - bowel perforation
• 5-15% in in various articles
• 3rd most common organ injured
• Most common - cause of sepsis related deaths
Zarour A, El-Menyar A, Khattabi M, Tayyem R, Hamed O, Mahmood I, Abdelrahman H, Chiu W, Al-Thani H. A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in he

5. Evaluation and Management
Bowel trauma - Mechanism
• RTA - seat belt, steering wheel, crash
• Direct Kick to abdomen - physical assault
• Fall of object over abdomen
• Penetrating injury - gunshot, impalement, stabs
• Animal attack
• Workplace related - suspension or reverse suspension

6. Initial Assessment and Plan
ATLS protocol
• A-B-C-D-E: Key to success
• Decision - stable or unstable - Exploratory Laparotomy or Damage control
• Addressing - shock - critically important
• Isolated to concomitant injuries
• Worse prognosis - concomitant
• Isolated Mesenteric injuries
• Dealing with duodenal trauma

7. Manegement strategies
Unstable patient
• Control haemorrhage - continue resuscitation
• Control contamination - 2nd option
• Divert the bowel - stoma
• Duodenum - unique
• Doubt - consider on worst side - do on best side

8. Manegement strategies
Stable patient
• Mechanism - clue to site of injury
• Esophagus - penetrating >>> blunt
• Stomach - penetrating
• Small bowel - blunt >>> penetrating
• Duodenum - seat belt, steering wheel , direct blow , penetrating
• Large bowel - blunt > penetrating
• Rectal - penetrating - rectum impalement injuries

9. Examination
External patter of injury - direct hint

10. AAST classification

16. Highest mortality
• 25cm - 4 parts
• 3-5% - blunt abdominal trauma
• Isolated injury - uncommon
• Pancreas, IVC and aorta
• 2nd part - most commonly injured
• Penetrating (78%) blunt (22%)
Duodenal injury

17. • Specific cases - steering wheel
or direct epigastric blow
• Severe abdominal pain
• Out of proportion - pancreas
associated
• Vomiting, retching with blood
• Nothing is accurate - diagnosis
• High index of suspicion
History &
Examination

18. • Abdominal x rays - not useful for
diagnosis
• USG - not diagnostic - raised high
index of suspicion
• CT scan - always recommend
• CT miss perforation up to 28-30%
• DPL unreliable - 40%
Radiology

19. Mild to moderate
• Stab wound
• 75% wall
• 3rd and 4th
• < 24 hours
• No Associated bile duct injury
Severe injury
• Blunt or missile injury
• More than 75%
• 1st & 2nd part injured
• > 24 hours
• Associated with bile duct injury
Severity of injury

20. Principles
1. Restoration gut continuity
2. Decompression of duodenal lumen
3. Provide external drainage
4. Provide Nutritional support
Management

21. Topic of debate ?
management of Bowel injury

22. Are we missing bowel injury?
Present - late - Traumatic bowel - mesenteric injury
• Clinical diagnostic - dilema
• CT scan - no sign of perforation
• USG - no conclusive
• 1% of all bowel injuries - mesenteric injury leading to bowel necrosis
• High index of suspicion
• Review CT - signs ischemia or Necrosis
• > 8 hr - associated with significant mortality - sepsis

23. Do we go for definitive surgery in 1st step?
Even if patient is stable-
Decision for definitive surgery - better other than duodenal trauma
Duodenum - high pressure zone
Complication or leak - higher > Grade 4 trauma
Principle of Duodenum management should always be followed

24. Should be do
single step surgery ?

25. Single layer or Double layer ?
Standard practice - depends on surgeon choice
Esophagus - single layer
Stomach and small Bowel - Double layer
Large bowel - single player
Doudenum - single layer
Emergency - Single layer is better

26. Single layer
or
Double layer
Journal of Clinical and Diagnostic Research. 2017 Jun, Vol-11(6): PC01-PC04
Equally Effective
And
More cost effective

27. Stoma or Anastomosis ?
Patient condition
• Hemodynamics - unstable
• Investigation - Hb , Alb, Lactate,
• Vasopressor - high dose
• Performing DCS
• Perineum wound, distal anastomosis
Live Problems are better than dead solutions

28. Do we have better grades for bowel injury ?
AAST best - adopted grading even for Bowel injury - Management
• Z score blunt trauma - non Validated
•
• Based on clinical , USG and CT
findings
• Used for early Diagnosis

29. PATI
Penetrating Abdominal trauma
Index
Not Widely Accepted
Only used in penetrating
trauma

30. Diagnostic Lap in Blunt Trauma ?
Blunt or Penetrating
Conclusion - laparoscopy in stable blunt abdominal trauma is safe and feasible, with expert hand. Avoid laparotom
and reduces LOS.
Journal of Surgical research, Australia

31. Occult Bowel Injury(CT)
1. Free fluid without SOI
2. Visceral Adhesions
Independent Predictors

33. Thank you
You may forget her,
but
she will never forget you
INTESTINE