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Abd Trauma - Cindy Kin.ppt
- 1. Abdominal Trauma Cindy Kin Trauma Conference 8 January 2007 Stanford General Surgery
- 2. Blunt Abdominal Trauma Mechanisms • Direct impact • Acceleration-deceleration forces • Shearing forces • No correlation between size of contact area and resultant injuries. • Abdomen = potential site of major blood loss.
- 3. Initial Evaluation and Treatment Is there a surgical intraabdominal injury? PE: guarding, peritoneal signs, tenderness, nausea. DRE. Lower rib fxs: 10-20% a/w spleen/liver injury Seatbelt sign a/w intestinal injury and mesenteric tears. Direct blunt trauma: rupture/tear of solid organs. Flank pain or contusion often late signs of retroperitoneal bleed Rapid resuscitation CXR, Pelvic X-ray FAST v DPL v CT Labs: Hct, WBC, amylase, UA, ABG, T+C
- 4. Blunt Abdominal Trauma INDICATIONS for CT • Blunt trauma with closed head injury • Blunt trauma with spinal cord injury • Gross hematuria • Pelvic fx, +/- suspected bleeding • Pt requiring serial exams, but will be lost to PE for prolonged period (ie orthopedic procedures, general anesthesia) • Pts with dulled or altered sensorium CONTRAINDICATIONS: unstable patients
- 5. Blunt Abdominal Trauma CT FAST DPL Accuracy 96% 95-99% 95% Sensitivity 97% 90-92% 100% Specificity 95% 88-90% 85% Drawbacks Stable pts only Cannot evaluate retroperitoneum. Cannot identify source of fluid. 0.5% miss intestinal perforation; cannot distinguish blood v bowel contents
- 6. Blunt Abdominal Trauma Shock with expanding abdomen, pnemoperitoneum, retroperitoneal air INDICATIONS FOR LAPAROTOMY Imaging: CXR FAST/DPL/CT Stable w/ peritoneal signs Peritoneal signs, HD unstable, sepsis + equivocal Observe, +/- re-image
- 7. Blunt Abdominal Trauma ROLE OF DIAGNOSTIC LAPAROSCOPY • Hemodynamically stable patients • Inadequate/equivocal FAST or borderline DPL (80K-120K RBC/HPF) • Intermittent mild hypotension or persistent tachycardia • Persistent abdominal signs/symptoms • Potential to decrease # of nontherapeutic laparotomies
- 8. Blunt Abdominal Trauma PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME ON FAST EXAM • Hemoperitoneum score on ultrasound a better predictor of need for therapeutic laparotomy than admission blood pressure and/or base deficit. • Hemoperitoneum characterized by measurement and distribution, scored • Ultrasound score >=3 statistically more accurate than combination of SBP and base deficit in determining which patient will undergo a therapeutic abdominal operation • 83% sensitivity, 87% specificity, 85% accuracy – McKenney et al, J Trauma 50:650-656, 2001
- 9. Blunt Abdominal Trauma HEPATIC AND SPLENIC INJURIES • Unstable patients: mandatory laparotomy • Stable patients: selective nonoperative approach Hepatic injury -Usually venous bleeding -Grade I-III: 94% success w/ nonop treatment -Grade IV-V: 20% amenable to nonop tx -HD stability, stable Hct, observation -Complications: delayed hemorrhage, bile leak, biloma, intra/peri hepatic abscess. -If stable with ongoing bleeding - angiographic embolization
- 10. Blunt Abdominal Trauma SPLENIC INJURIES • Often arterial hemorrhage, therefore nonoperative management less successful. • Predictive factors for nonop success: – Localized trauma to flank/abdomen – Age<60 – No associated trauma precluding obs – Transfusion <4u prbcs – Grade I-III • Grade IV-V: almost invariably require operative intervention • Delayed hemorrhage (hours to weeks post-injury): 8-21%
- 11. Blunt Abdominal Trauma RETROPERITONEAL HEMORRHAGE • Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx, retroperitoneal bowel. • Minimal signs on examination; flank pain and contusion are late findings • FAST/DPL negative; CT can identify
- 12. Blunt Abdominal Trauma DUODENAL AND PANCREATIC INJURY • Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitoneal air on plain abdominal films. • DPL unreliable. • At laparotomy, central upper abdominal retroperitoneal hematoma, bile staining, or air: mandates visualization and examination of panc/duo • Duodenal injury: – 80% lacs (G I-III) - primary repair – 10-15% RYDJ, pyloric exclusion, Whipple • Pancreatic injury – Late complications: time from injury to tx • Abscess, pseudocyst, fistula.
- 13. Blunt Abdominal Trauma DIAPHRAGMATIC RUPTURE • 3-5% of all abdominal injuries, L>R • May p/w few signs, need high index of suspicion – Injury mechanism: compartment intrusion, deformity of steering wheel, need for extrication, fall from great height – Prominence/immobility of L hemithorax – NGT in chest, bowel sounds in thorax – CXR: (50% with non-dx initial CXR): • Obliteration of L diaphragm on CXR • Elevation/irregularity of costophrenic angle • Pleural effusion • Confirm with GI contrast studies, dx laparoscopy • Ex-lap and repair
- 14. Blunt Abdominal Trauma SMALL BOWEL INJURY • Mechanism: rapid deceleration with compression, shearing • Often at points of fixation: Treitz, ileocecal valve, prior adhesions, mesentery. • Chance fracture (transverse fx of lower thoracic/lumbar vertebral body) raises index of suspicion for SB injury • Dx: DPL may be (-) for 6-8h after intestinal perforation, Clinical signs absent until 6-12h post-injury. • Delayed perforation: due to direct injury, transmural contusion, ischemia from mesenteric vascular injury; usually presents w/in days.
- 15. Blunt Abdominal Trauma INJURY TO COLON AND RECTUM • Mechanism: rapid deceleration with steering wheel compression • uncommon • Disruptions of colonic wall or avulsion injury of mesentery • Present with hemoperitoneum, peritonitis.
- 16. Penetrating Abdominal Trauma Evaluation • Any penetrating wound between nipples and gluteal crease = potential intra- abdominal injury. • Stab wounds: stratify based on location • GSW: higher potential for serious injury.
- 17. Penetrating Abdominal Trauma Evaluation of Stab Wounds • Local exploration • DPL – 5cc gross blood on aspiration – >20K RBC/mm3 – >500 WBC/mm3 – >175U amylase/100mL – Bacteria – Bile, Food particles • CT – Limited ability to dx hollow organ injury – Useful for posterior SW • FAST – Limited, high false negative rate – Useful for pericardial injuries • Diagnostic laparoscopy – Useful for assessing peritoneal penetration, diaphragm injury – Shorter LOS than negative laparotomy
- 18. Penetrating Abdominal Trauma Stab Wounds: Stratification by loci Lower Chest Anterior Abdominal Flank Peristernal Potential Mediastinal Back
- 19. Penetrating Abdominal Trauma Stab Wounds: Stratification by loci Lower Chest Anterior Abdominal Explore locally, manage expectantly with serial PE Flank Peristernal Potential Mediastinal Back
- 20. Penetrating Abdominal Trauma Stab Wounds: Stratification by loci Lower Chest Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal Back
- 21. Penetrating Abdominal Trauma Stab Wounds: Stratification by loci Lower Chest Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal Back admit for obs
- 22. Penetrating Abdominal Trauma Stab Wounds: Stratification by loci Lower Chest ?Thoracoscopy, Laparoscopy Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal Back admit for obs
- 23. Penetrating Abdominal Trauma Stab Wounds: Stratification by loci Lower Chest ?Thoracoscopy, Laparoscopy Anterior Abdominal Explore locally, manage expectantly with serial PE Flank explore locally triple contrast CT Peristernal Potential Mediastinal CVP monitor, U/S Observe >6h, repeat CXR Back admit for obs
- 24. Penetrating Abdominal Trauma Gunshot Wounds • Usually require urgent exploration • Evaluation for peritoneal penetration v tangential GSW. – CT, diagnostic laparoscopy – Use of DPL controversial due to high false negative rate • Ballistics: – Civilian=lower velocity handgun missiles; military = higher velocity rifle missiles – Permanent and temporary cavities: Yaw, Bullet size and type – Shotgun: • Short range: high-velocity and more concentrated • Distant range: multiple low-velocity projectiles, more diffuse, less severe • Antibiotics: cefotetan or cefoxitin in ED
- 25. Penetrating Abdominal Trauma ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATING GSW AND NEED FOR LAPAROTOMY • 66 GSW underwent DL, 2/3 of GSW in upper torso • Peritoneal penetration ruled out in 62% • 29% had therapeutic ex-lap, 5% had non-therapeutic ex-lap, 4% had negative ex-lap • Hospital stay: – 4.3 days - negative DL and associated injuries – 8.6 days - laparotomy – 1.1 days - negative DL and no associated injuries. – Fabian et al, Ann Surg 1993; 217:557
- 26. Penetrating Abdominal Trauma IMPACT OF DIAGNOSTIC LAPAROSCOPY ON NEGATIVE LAPAROTOMY RATE • Retrospective review 817 pts who underwent ex-lap for abdominal GSW over 4yr: negative ex-lap rate = 12.4% – 22% morbidity, LOS 5.1days • Review of 85 pts with abdominal GSW evaluated with DL – Negative DL in 65%, no missed injuries, no subsequent need for ex-lap; 3% morbidity rate (one pt had urinary retention), LOS 1.4days – Positive DL in 35%, 28 of 30 underwent ex-lap, 86% therapeutic and 14% nontherapeutic (remaining 2 were observed for nonbleeding liver lacs) – Sosa et al. J Trauma 1995;38(2):194
- 27. Penetrating Abdominal Trauma IMPACT OF DIAGNOSTIC LAPAROSCOPY ON NEGATIVE LAPAROTOMY RATE • Prospective study of 121 patients with tangential GSW, HD stable • 65% negative DL • Of 25% positive DL, 92.8% (39) underwent ex-lap – 82% (32) therapeutic, 15.4% (6) nontherapeutic, 2.5% (1) negative • No false negative DLs, no delayed laparotomies • Sensitivity for peritoneal penetration 100% – Sosa et al. J Trauma 1995;39(3):501
Editor's Notes
- EVALUATION AND INDICATIONS FOR CELIOTOMY
- Seat belt sign a/w intest injury esp at prox jej and terminal ileum.
- IN the past, mandatory exploration for suspected abdominal injury resulted in unacceptably high negative and nontherapeutic laparotomy rates, which are associated with 18% and 45% morbidity rates, respectively. We have evolved to using diagnostic modalities to identify those who do not require a laparotomy. Low specificity of DPL is reason that it’s associated with 20%rate of nontherapeutic ex-lap.
- + DPL: Initial aspiration blood >=5cc Rbc >100,000 mm3 WBC>500mm3 Presence of bile, bacteria, food particles Presence of lavage fluid via foley or chest tube or NG Presence of pleural effusion on postlavage cxr, suggesting occult diaphragmatic rupture.
- 12yoM boogi boarding, presented 16h after injury. HR 130, BP 100/60. RUQ pain with guarding. Non op.
- Both were sustained by kids boogie boarding, both managed nonoperatively. Spleen: 14yo boy rammed into boogi board, presented 6h later with worsening LUQ pain. Tachy to 130, BP 100/60. Non op. no transfusions.
- In absence of peritonitis, HD instability, intraab fluid on FAST, may stratify by loci. 25% of stab wounds fail to penetrate peritoneal cavity, therefore selective mgmt of stab wounds. This practice is supported by complication rates of 8% and 41% for negative laparotomies or nontherapeutic laparotomies. Avg LOS for uncomplicated nontherapeutic laps 5.1 days; Avg LOS for complicated nontherap laps 11.9 days. Nance etal: 2000pts. Clinical obs with serial PE in stable pts with SW. Demetriades/Robinowitz: 651 pts. 53% laparotomy, 47% obs. Of Obs, only 2.9% req’d subsequent surgery. Overall incidence of negative laparotomy 5%. Anterior ab: ant to ant ax line, below costal margin, above inguinal lig. in absence of hypotension, peritonitis, evisceration, intraabdominal fluid on FAST - Flank: b/n anterior and posterior axillary lines, lower ribs to iliac crest Back: posterior to post ax lines. If no anterior abd tenderness… Lower chest: below nipples in ant/lat/post Peristernal potential mediastinal: cardiac silhouette, base of neck in suprasternal notch.
- 35% of pts with ant ab wounds will not have fascial penetration Even if anterior fascia penetrated, still 25% non therapeutic laparotomy rate.
- Due to retroperitoneal attachments of L and R colon, and duodenum, need triple contrast CT.
- Admit for obs due to risk for hepatic/posterior duodenal injury
- Lower Chest: potential for intra-thoracic and intraabdominal injury and transdiaphragmatic traverse. Pressure gradient b/n abdominal and pleural space may cause diaphragm wound enlgment and herniation of ab contents. Thoracoscopy to visualize diaphragm. Diagnostic dilemma.
- Peristernal potential mediastinal: Cardiac tamponade, pneumothorax. CVP monitoring, U/S to dx. Observe atleast 6h, repeat CXR for developing PTX.
- In absence of peritonitis, HD instability, intraab fluid on FAST, may stratify by loci. Anterior ab: ant to ant ax line, below costal margin, above inguinal lig. in absence of hypotension, peritonitis, evisceration, intraabdominal fluid on FAST - Flank: b/n anterior and posterior axillary lines, lower ribs to iliac crest Back: posterior to post ax lines. If no anterior abd tenderness… Lower chest: below nipples in ant/lat/post Peristernal potential mediastinal: cardiac silhouette, base of neck in suprasternal notch.