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Blunt trauma abdomen
- 1. BLUNT TRAUMA ABDOMEN SURG LT CDR K S PATEL
- 2. Scope • Types • Regional anatomy • Causes • Mechanism • Examination • Investigation • Management
- 3. Types of Abdominal Trauma 1.Blunt Trauma- Any force to abdomen which does not leave open wound. 2.Penetrating Trauma -Stab -Gun shot Injury
- 4. Regions of Abdomen • Anterior abdomen • Flank • Posterior abdomen
- 5. Internal anatomy • Intra-thoracic • Pelvic • Retroperitoneal • True abdomen
- 6. Mechanism of Injury • CRUSHING- Direct application of a blunt force to the abdomen • SHEARING- Sudden decelerations apply a shearing force across organs with fixed attachments • BURSTING- Raised intraluminal pressure by abdominal compression in hollow organs can lead to rupture • PENETRATION -Disruption of bony areas by blunt trauma may generate
- 7. Hollow vs Solid Organ Hollow organ injury • Highly irritating and infectious content releases into peritoneal cavity, producing a painful inflammatory reaction-Peritonitis • Stomach, Intestine, Gall bladder, Urinary bladder, Uterus Solid organ injury • Causes several internal bleeding • Bleed causes peritonitis • Shock may overshadow peritonitis
- 8. CAUSES • RTA with motor vehicle accident 60% • Direct blow to abdomen 15% • Fall 9% • Domestic violence
- 9. PRIMARY SURVEY • Identification & treatment of life threatening conditions • Airway , with cervical spine precautions • Breathing • Circulation • Disability-AVPU (neurological status) • Exposure-remove all clothes
- 10. EMERGENCY CARE • I V fluids • Control external bleeding • Dressing of wounds • Protect eviscerated organs with a sterile dressing • Stabilize an impaled object in place • Give high flow oxygen • Keep the patient warm • Analgesics
- 11. SECONDARY SURVEY • General &Systemic Examination-to identify all occult injuries . • Special attention to Back, Axilla , Perineum • P/R - sphincter tone ,bleeding ,perforation , high riding prostate • Foley’s catheter- monitor urine out put • Nasogastric tube
- 12. SECONDARY SURVEY AMPLE History A: Allergy M: Medications P: Past medical history L: Last meal E: Event
- 13. EXAMINATION Cullen’s Sign: Bluish discoloration around umbilicus. Diffusion of blood along periumbilical tissues Hemoperitoneum Severe pancreatitis 13
- 14. EXAMINATION Grey-Turner’s Sign: Bluish discoloration of the flanks.Retroperitoneal Hematoma hemorrhagic pancreatitis. Kehr’s sign: Referred pain, Right shoulder irritation of the diaphragm (Splenic injury, free air,intra-abdominal bleeding)
- 15. EXAMINATION Balance’s Sign: Dullness on percussion of the left upper quadrant ruptured spleen Labia and Scrotum : Pooling of blood from abdominal and pelvic cavities.
- 16. • Seat belt sign
- 17. London sign
- 18. Examination Palpation: -Mass -Tenderness -Rebound tenderness - Guarding /Rigidity -Signs of peritonitis -# Ribs -Chest & Pelvic compression test Auscultation : 1. Bowel sounds in the thoracic cavity (Diaphragmatic rupture) 2. Haemothorax
- 19. INVESTIGATIONS • FAST • X-Ray Chest & Abdomen • USG • CT Scan • Diagnostic Peritoneal Lavage • Diagnostic Laparoscopy
- 20. Focussed Assessment with Sonography in Trauma (FAST) • Rapid , Accurate • Sensitivity 86- 99% • Can detect 100 mL of blood • Cost effective • Four different views- Pericardiac Perihepatic Perisplenic Peripelvic space • Eliminates unnecessary CT scans • Helps in management plan
- 21. PLAIN X-RAY CHEST & ABDOMEN • Pneumotharax, Haemothorax • Free air under diaphragm • Nasogastric tube, bowel loops in the chest • Elevation of the both /Single diaphragm • Lower Ribs # -Liver /Spleen Injury • Ground Glass Appearance – Massive Hemoperitoneum • Obliteration of Psoas Shadow –Retroperitoneal Bleeding • #vertebra
- 22. USG ADVANTAGE • Easy & Early to Diagnose • Noninvasive • No Radiation Exposure • Resuscitation/Emergency room • Used in initial Evaluation • Low cost DISADVANTAGE • Examiner Dependent • Obesity • Gas interposition • Low Sensitivity for free fluid less 500 mL • False –Negative retroperitoneal & Hallow viscus injury
- 24. DIAGNOSTIC PERITONEAL LAVAGE • Rapid & Accurate test used to identify intra- abdominal injuries • Predictive value of greater than 90% • The RBC count for lavage fluid is > 1,00,000/cu m.m. • A WBC count > 500/cu m.m. • Test is highly sensitive to presence of intraperitoneal blood • However specificity is low
- 25. DPL Indications • Unexplained Shock • Altered sensorium (Head injury , Drug) Contraindications • Clear indication for Exploratory Laparotomy • Relative -Abdominal wall infection -Pregnancy -coagulopathy
- 26. CT SCAN • Gold Standard • Haemodynamically Stable • Excellent imaging of pancreas, duodenum and GU system • Standard for detection of solid organs injury. • Source and amount of bleeding • Other assoc injuries e.g. Vertebral & Pelvic # & injury in the thoracic cavity . •High Specificity-95%
- 28. CT SCAN Contraindication: • Clear indication for Laparotomy • Haemodynamically Unstable • Allergy to contrast media
- 30. RECOMMENDATIONS • Hemodynamically unstable or with diffuse abdominal tenderness emergently for laparotomy (level 1) • Hemodynamically stable with unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1). • A routine laparotomy is not indicated in hemodynamically stable patient without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2).
- 31. • A routine laparotomy is not indicated in hemodynamically stable patients with abdominal GSWs if the wounds are tangential and there are no peritoneal signs (level 2). • In patients selected for initial NOM, abdomino-pelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2). • Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2)
- 32. SOLID ORGAN INJURIES • Grading of injured solid organs such as Spleen, Liver & Kidneys are on the basis of • subcapsular hematoma • capsular tear • parenchymal lacerations • avulsion of vascular pedicle • Bleeds significantly and cause rapid blood loss • Difficult to identify injury by physical exam • Repeated assessment is required to make the diagnosis
- 33. SPLENIC INJURY • Most common intra- abdominal organ to injured (40-55%) • 20% due to left lower rib fractures • Arterial hemorrhage
- 34. Splenic injury • Conservative management : -Hemodynamic stability - Negative abdominal examination -Absence of contrast extravasation in CT - Absence of other indication of Laprotomy -Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm) Monitoring • Serial abdo examinations & Haematocrit are essential • Success rate is >80%
- 35. SPLENIC INJURIES Operative Management Capsular tears (I)- Compression & topical haemostatic agent Deep Laceration (II) and (III) - Horizontal mattress suture or Splenorrhaphy Major Laceration not involving hilum (IV)- Partial Splenectomy Hillar injury (V)–Total Splenectomy Grade IV-V: almost invariably require operative intervention Success rate of Splenic salvage procedure is 40-60%
- 36. LIVER INJURY • 2nd most common organ injured (35-45%) in BTA • RTA and fights are responsible for 50% of liver injury • Venous bleeding • Around 85% of all patients remain stable • CT mainstay in stable pt.
- 37. Liver injury
- 38. LIVER INJURY • 50% stop bleeding spontaneously by the time of surgery Non Operative Mx • Haemodynamically Stable • No other intra-abdominal injury require surgery • < 2 units of Blood Transfusion required • Hemoperitoneum <500 ml on CT • Grade I-III(subcapsular & intr-perenchymal hematoma) 38
- 40. LIVER INJURY OPERATIVE MANAGEMENT • Packing - Bleeding can be stopped by packing -Pack removed after 48 hr -Haemostatic agents -34 % survival in packing only
- 41. • Suturing: -Simple suture -Deep mattress suture • Laceration: -Mesh hepatorrhaphy -Omental flap to cover the laceration • Lobar Resection • Ligate or repair damaged blood vessels & bile duct • Mortality due to liver injury is 10% LIVER INJURY OPERATIVE MANAGEMENT
- 43. PANCREATIC INJURY • 10-20% of abdomen injury. • Crush, direct blow to abdo & Seat belt injury • Associated with duodenal injury, Vascular injury & liver injury • Pancreatic enzymes are caustic, source of massive systemic inflammation and subsequent poor outcomes. • Diagnosis – Difficult, CECT :- malperfusion of the pancreatic parenchyma surrounding fluid • Hematoma • Extent of parenchymal injury and degree of ductal involvement poorly characterize • High index of suspicion –rib/ vertebra fracture
- 44. Pancreatic Injury The injury involves the pancreatic neck and appears as a 2-cm segment of nonperfused pancreas tissue with surrounding edema as identified by the arrow
- 45. PANCREATIC INJURY Management • Exposure of the entire pancreas is required • Mobilization:- hepatic flexure gastrocolic ligament to retract the transverse colon and mesocolon inferiorly. • Ext drainage imp component • Distal feeding access provide early enteral nutrition
- 47. RENAL INJURY • Frequently overlooked • Mechanism: Blunt , Penetrating # lower ribs or spinous process, Crush abdominal Pelvic injury Direct blow to flank or back Fall RTA
- 48. RENAL INJURY Diagnosis 1.History ,Clinical examination 2. Presentation :Shock, hematuria & pain 3. Urine: gross or microscopic hematuria 5.X-ray KUB IVP 6.CT Scan abdomen 7. USG The degree of hematuria may not predict the severity of renal injury
- 49. RENAL INJURY Classification of Injury • Grade I : Contusion or Subcapsular Hematoma • Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation • Grade III: Laceration >1cm with urinary Extravasation • Grade IV: Parenchymal Laceration deep to CM Junction • Grade V: Renovascular injury
- 50. MANAGEMENT OF RENAL INJURY About 85% of trauma can be managed conservatively Renal Contusion : Conservatively Renal exploration : Indication • Deep cortico-medullary Laceration with extravasation • Large perinephric Hematoma • Renovascular injury • Uncontrolled bleeding
- 51. DIAPHRAGMATIC INJURY • Incidence -0.8%-1.6% in BTA • High index of suspicion required , may be missed. • Presentation may be delayed • Imaging Nasogastric tube seen in the thorax Abdominal contents in the thorax Elevated hemidiaphragm Distortion of diaphragmatic margin.- -Primary repair with interrupted horizontal mattress suture
- 53. HOLLOW VISCUS INJURIES Gastric Injury : Penetrating trauma Blunt trauma abdomen 1% Causes Penetrating Injury -Crushing Against the Spine -CPR -Vigorous Ventilation with ET Tube in the Esophagus -Heimlich Maneuver Diagnosis : X-Ray chest & Abdomen CT scan Diagnostic Peritoneal Lavage During Surgical Exploration T/t : Expl. Laparotomy with Primary Repair
- 54. DUODENAL INJURY Isolated Duodenum injury rare Incidence - 3-5% Cause :Penetrating injury: most common Steering wheel injury Assault Fall Associated with other intra-abdominal injury Plain X-ray –Free air in abdomen -Intraoperative diagnosis Mx : Primary Repair 80% case Roux-en –Y duodenojejunostomy 20%
- 55. HOLLOW VISCUS INJURIES Small Intestine& Colonic Injuries Commonly Injured in Penetrating injury Blunt Trauma -Incidence 5% -20% Mechanism : -Crush Injury -At Fixed point DJ & IC Junction Mx : Exploratory Laprotomy Primary repair Resection with anastomosis End colostomy Primary repair with diverting colostomy
- 56. BLADDER INJURY • 70% of bladder Injury are associated with pelvic fracture . • Hematuria Type 1.Extraperitoneal Rupture-by bony fragment • 2. Intraperitoneal Rupture- at dome when blow in distended bladder • Diagnosis -1. Clinical 2. Cystography T/t 1. Intraperitoneal – closure with absorbable sutures +SPC 2:Extraperitoneal Rupture : Foley’s catheter -10 -14 days
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