2. Spleen is the most common organ involved in blunt
trauma.
Often in blunt trauma first part of the jejunum or
ileocaecal junction gives way (blow out effect) due
to traction often causing complete transection of
bowel horizontally close to the junction.
It is due to force of the mobile part of the bowel
over the fixed part.
3. Abrasion over the abdominal skin suggests the
possibility of internal injury (London’s sign).
4. MECHANISM OF INJURY: BLUNT
Compression, crush, or sheer injury
to abdominal viscera: deformation
of solid or hollow organs, rupture
(e.g. small bowel, gravid uterus)
Deceleration injuries: differential
movements of fixed and non-fixed
structures (e.g. liver and spleen
laceration at sites of supporting
ligaments)
6. GENERAL CLINICAL FEATURES
Features of shock—pallor, tachycardia,
hypotension, cold periphery, sweating, oliguria.
Abdominal distension.
Pain, tenderness, rebound tenderness, guarding
and rigidity, dullness in the flank on percussion.
Respiratory distress, cyanosis depending on the
amount of blood loss.
Bruising over the skin of the abdominal wall.
Features specific of individual organ injuries.
7. DIAGNOSTIC PERITONEAL LAVAGE
Introduced by Root (1965)
Today DPL is performed less frequently, as it has been
replaced by focused abdominal sonography for trauma
(FAST) and helical computed tomography (CT).
DPL is the only invasive test of the three, but while
lacking organ specificity it remains the most sensitive
test for mesenteric and hollow viscus injuries
8. INDICATIONS FOR DPL IN BLUNT TRAUMA
1. Hypotension with evidence of
abdominal injury
2. Multiple injuries and unexplained
shock
3. Potential abdominal injury in
patients who are unconscious,
intoxicated, or paraplegic
4. Equivocal physical findings in
patients who have sustained high-
energy forces
9. CONTRAINDICATIONS OF DPL
Absolute :
Peritonitis
Injured diaphragm
Extraluminal air by x-ray
Significant intraabdominal injury by CT scan
Intraperitoneal perforation of the bladder by cystography
Relative :
Previous abdominal operations (because of adhesions)
Morbid obesity
Gravid Uterus
Advanced cirrhosis (because of portal hypertension and the
risk of bleeding)
Preexisting coagulopathy
11. 3 methods of introducing DPL catheter
1.closed approach(seldinger) –uncontrolled depth of
penetration.
2.Open procedure-safer but time
consuming,introduces air into peritoneal cavity.
3.semiopen technique(at infra umbilical region)-
prefered,quick,easy,reliable.
12.
13.
14. PREFERRED SITE OF DIAGNOSTIC PERITONEAL
LAVAGE
Standard adult :Infraumbilical midline
Standard pediatric: Infraumbilical midline
2ed &3ed trimester pregnancy :Suprauterine
Midline scarring :Left lower quadrant
Pelvic fracture: Supraumbilical
15. EVALUATION OF DPL
Fluid is sent for: cell count, amylase, alk phos, presence of bile
Index Positive value
Aspirate Blood >10 mL
Fluid Enteric content
Lavage RBC > 100,000/mL
WBC > 500/mL
Amylase >175 U/dL
Alk Phos > 3 IU
Bile Confirmed
Negative RBC < 50,000/mL
WBC < 100/mL
Amylase < 75 U/dL
16. DIAGNOSTIC PERITONEAL LAVAGE
RBC Count Incidence of visceral damage
>100,000 95%
20,000-100,000 15-25% Warrant further investigation
<20,000 < 5%
Complications of DPL: Perforation of small bowel, mesentery,
bladder and retroperitoneal vascular structures.
Limitation: offers no information about status of retroperitoneal
organs nor allow determination of which organ has been injured.
17. FAST(FOCUSED ABDOMINAL SONOGRAPHY FOR
TRAUMA) : STRENGTHS AND LIMITATIONS
Strengths
Rapid (~2 mins)
Portable
Inexpensive
Can be performed serially
Useful for guiding triage
decisions in trauma patients
Limitations
Does not typically identify
source of bleeding,
Requires extensive training to
assess parenchyma reliably
Limited in detecting <250 cc
intraperitoneal fluid
Particularly poor at detecting
bowel and mesentery damage
(44% sensitivity)
Difficult to assess retro
peritoneum
Limited by habitus in obese
patients
18. FAST
Four View Technique:
Morrison’s pouch (hepatorenal)
Douglas pouch (retropelvic)
Left upper quadrant (splenic view)
Epigastric (View pericardium)
21. FAST: ACCURACY
For identifying hemoperitoneum in blunt
abdominal trauma:
Sensitivity 76 - 90%
Specificity 95 - 100%
The larger the hemoperitoneum, the higher
the sensitivity. So sensitivity increases for
clinically significant hemoperitoneum.
FAST can detect?
1. 250 cc total
2. 100 cc in Morison’s pouch
22. FAST AND CT
CT is far more sensitive than FAST for
detecting and characterizing abdominal
injury in trauma. The gold standard for
characterizing intraparenchymal injury.
“Death begins with a CT.” Never send an
unstable patient to CT. FAST, however,
can be performed during resuscitation.
23. EVALUATION
Blunt trauma patients who are unstable and have intra-
abdominal fluid identified on FAST require an emergent
laparotomy to manage bleeding.
If FAST is unavailable, aspiration of 10 mL or more of
gross blood on DPL also suggests an intra-abdominal
source of hemorrhage requiring emergent operation.
Furthermore, patients with peritonitis require
abdominal exploration to evaluate for hollow visceral
injury.
Other patients will undergo further workup of the
abdomen to evaluate for intra-abdominal injury.
24.
25. ABDOMINAL CT
The mainstay of imaging for the stable blunt trauma
Has led to the emergence of nonoperative
management of many solid abdominal organ
injuries.
Performed with IV contrast timed to capture the
portal venous phase, which best demonstrates the
vasculature and visceral perfusion of the solid
abdominal organs.
26. Excellent visualization of the solid organs, allowing
the characterization of injury severity (injury grade)
and the recognition of active bleeding, which
appears as contrast extravasation.
Imaging findings assist in making management
decisions regarding the need for operative,
nonoperative, or angiographic therapy
27. The retroperitoneal structures are also well
visualized on CT, identifying injuries that are difficult
to evaluate with FAST or DPL.
28. DPL demonstrating more than 100,000 red blood
cells/mm3 is indicative of intra-abdominal injury and
historically mandated a laparotomy.
The high nontherapeutic laparotomy rate
associated with this practice has led to the
nonoperative principles commonly used today
because a large percentage of abdominal
structures that had bled were no longer bleeding at
the time of abdominal exploration.
The frequent lack of bleeding at laparotomy
suggested that the patient’s physiologic condition
was more important than the presence of intra-
abdominal blood when making treatment decisions.
29. Abdominal CT is less sensitive for detecting hollow
visceral injury.
Hollow viscous injury is suggested by the recognition of
bowel wall thickening, inflammation in the surrounding
adipose tissue seen as stranding, or presence of free
intraperitoneal fluid.
Administration of oral contrast is not necessary and
might increase the risk of vomiting with aspiration.
It is paramount that the presence of unexplained free
fluid on imaging be carefully evaluated and a high index
of suspicion for bowel injury be maintained.
30. Frequently, a combination of these radiographic
findings, with clinical signs and symptoms such as
an abdominal seatbelt mark or tenderness on
examination, are suggestive and may require
exploration.
A challenging scenario is the identification of intra-
abdominal fluid on imaging without the presence of
solid organ injury to explain its presence.
31. In a significant percentage of cases, this fluid
represents blood from a mesenteric tear
Fluid visualized in more than one abdominal
quadrant suggestive of a bowel injury requiring
laparotomy.
32.
33. SPLENIC INJURY
Splenic injury occurs commonly following road
traffic accidents, other blunt injury or
penetrating/stab injuries.
Most often associated with fracture of left lower
ribs, haemothorax, injury of liver (left lobe
commonly, occasionally both lobes), bowel, tail of
pancreas, left kidney.
Injury is more common and severe in enlarged
spleen, i.e. in malaria, tropical splenomegaly,
infectious mononucleosis.
Spleen is the most common solid organ injured in
blunt abdominal trauma.
34. TYPES OF INJURY
1. Splenic subcapsular haematoma: After initial
injury patient remains asymptomatic for a short
period. But this haematoma ruptures later causing
torrential haemorrhage.
2. Clean incised wound over the surface
3. Lacerated wound.
4. Splenic hilar injury causes torrential
haemorrhage, may even cause death. So
immediate surgical intervention and splenectomy
is done.
5. Splenic injury associated with other injuries (left
kidney, left colon, small bowel, pancreas,
diaphragm, left lung).
35. PRESENTATION
Features of shock: tachycardia, hypotension, fever,
restlessness, pallor.
Hemoperitoneum: abdominal distension.
Diffuse abdominal tenderness, localised guarding in
the left upper quadrant.
Death sometimes.
36. Dullness in the left flank which does not shift, as
the collected blood gets clotted. Dullness without
shifting— Ballance’s sign.
Clot collected under the left side of the diaphragm
irritates it and the phrenic nerve causing refered
pain in the left shoulder—Kehr’s sign.
There may be left sided haemothorax with
fracture of ribs.
37. Delayed presentation is also possible due to
formation of subcapsular haematoma which later
gives way.
Initially gets temporarily localized by greater
omentum, later giving way leading to torrential
bleeding.
Blood clot temporarily seals off the bleeding which
later gets dislodged causing severe bleeding.
This time period in between is called ‘latent period
of Bandet’.
38. INVESTIGATIONS
U/S abdomen is the investigation of choice
Hb%, PCV, blood grouping and cross matching.
Adequate amount of blood must be kept ready for
transfusion.
CT scan will show type of splenic injury and its
class.
39. PLAIN X-RAY ABDOMEN FINDINGS
Obliteration of splenic outline
Obliterarion of psoas shadow (most important
feature)
Indentation of fundic gas shadow
Fracture of lower ribs
Elevation of left side of diaphragm
Free fl uid in the abdomen between coils of
intestine
40. CT FINDINGS
Three CT findings correlate with the need for
intervention:
Devascularization or laceration involving 50% or
more of the splenic parenchyma
Contrast blush greater than one centimeter in
diameter (from active extravasation of IV contrast
or pseudoaneurysm formation
A large hemoperitoneum.
42. CT shows a subcapsular hematoma with a splenic laceration extending from the capsule
to the hilum with an intraparenchymal hematoma (blue arrow). Within the
intraparenchymal and subcapsular hematomas are areas of hyperdensity that represent
active extravasation (red arrow).
43. COMPLICATIONS OF SPLENIC
RUPTURE/TRAUMA
Blood loss.
DIC.
Sepsis.
Splenic artery pseudoaneurysm.
Splenic arteriovenous fi stula.
Problems of associated injuries like of pancreas.
44. GRADE OF SPLENIC INJURY
I Hematoma subcapsular, <10%
Laceration < 1cm deep
II Hematoma subcapsular, 10-50%
intraparenchymal, <5 cm
Laceration 1-3 cm deep
III Hematoma >50%, ruptured, >5cm
Laceration >3 cm, + trabecular vessels
IV Laceration segmental or hilar vessel
with major devascularisation
V Laceration shattered spleen, avulsion
45. CLASSIC CRITERIA FOR NON OPERATIVE
MANAGEMENT
Hemodynamic stability
Negative abdominal examination
Absence of contrast extravasation on CT
Grade 1 injuries
Grade 2 injuries
Grade 3 injuries that are isolated
46. CRITERIA FOR OPERATIVE MANAGEMENT
OF SPLENIC INJURY
Grade IV and V injuries
Instability at admission, when the exact location of
bleeding is unknown
After failed nonoperative management
47.
48.
49. OPERATIVE MANAGEMENT
Capsular tear-compression/haemostatic agents
Deeper lacerations-absorbable mattress sutures
Major lacerations involving <50% of parenchyma
and not extending into hilum-segmental/partial
splenectomy
Extensive injury involving hilum or central portion of
spleen-splenectomy
50. A more recent advance in the management of
splenic injury has been the use of angiography
Angiography can identify specific sites of bleeding
from the splenic parenchyma and underlying
segmental or trabecular vessels
One major benefit of angiography is the potential to
obstruct sites of bleeding endovascularly using
angioembolization
