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Principles Of Trauma
Management
Abdominal Trauma
Hepatobiliary And Splenic Trauma
Moderator
Prof Vinod Jain
Dr. Geetika Nanda Singh
Dr.Parijat Suryavanshi
Dr.Ashish Chaubey
Presentation Statement
Unrecognized abdominal and pelvic
injuries continue to be A cause of
preventable death
External Landmarks
Classification of injuries
 Blunt trauma
 Penetrating trauma
 Iatrogenic trauma
Mechanism of Injury
When should you suspect abdominal
injury?
• Speed
• Point of impact
• Intrusion
• Safety devices
• Position
• Ejection
• Weapon
• Distance
• Number, location of wounds
• Combined mechanism
Blunt
Penetrating
Explosion
Blunt Force Mechanism
• Spleen
• Liver
• Small bowel
• Pelvis
Common Injuries
Penetrating Mechanism
• Stab
• Low energy, lacerations
• Gunshot
• Ballistics
• Type of weapon
• Shrapnel
• Shotgun
• Distance from target
• Spread of projectiles
• Explosion / blast
Any Organ at Risk
Case Scenario
● 35-year-old male passenger in high-
speed motor vehicle collision
● Blood pressure: 105/80; Pulse: 110;
respiratory rate: 18; GCS Score = 15
● Complaining of pain in Abdomen
What injuries do you suspect,
and how would you manage this patient?
Assessment
How do I determine if there is an
abdominal injury?
Physical Exam
• Inspection
• Auscultation
• Percussion
• Palpation
Adjuncts of Primary Survey
• Pelvic x-ray
• C X ray
• FAST
• DPL
 Inspection: abrasions, contusions, lacerations,
deformity, entrance and exit wounds to determine
path of injury…………..
(Grey-Turner, Kehr, Balance, Cullen, seat belt sign….)
 Palpation: elicit superficial, deep, or rebound
tenderness; involuntary muscle guarding
 Percussion: subtle signs of peritonitis; tympany in
gastric dilatation or free air; dullness with
hemoperitoneum.
 Auscultation: bowel sounds may be decreased(late
finding).
Physical Examination
Physical Examination
• Accuracy Only 60-65%
• Serial Examination- Best Sensitivity And
Negative Predictive Value
• Primary Objective-rapidly Identify The Patient
Who Needs A Laparotomy
• Pulse, Blood Pressure, Capillary Refill And
Urine Output—hypovolemia +
Abdominal Signs
• Most important- Peritonitis
HOW TO MANAGE SUCH PATIENT??
PRIMARY SURVEY (ABCDE
approach,damage control
resuscitation,Management of shock)
SECONDAY SURVEY (rapid diagnosis and
prompt management,damage control
surgery)
GRADING OF INJURY(AAST GUIDELINE)
MANAGEMENT OF SPECIFIC INJURIES AS
PER STANDARD PROTOCOL(WSES
GUIDELINE)
Primary Survey-ATLS Approach
 A – Intubation may be required if pt. is in
shock, hypotension or unconscious or in need
for ventilation
 B – Watch for hemo-pneumothorax in both
blunt and penetrating thoracoabdominal
injuries
 C – Start with 1 L crystalloid (If active bleeding
you MUST FIND & STOP THE BLEEDING)
 D – May see associated thoracolumbar #es
 E – Watch for other injuries
Secondary Survey
History :Not necessary
S.A.M.P.L.E
S: Symptoms:Pain,vomiting,hematuria,hematochezia,
dyspnea, respiratory distress
A: Allergies
M: Medications
L:Last meal
E: Events: Mechanism of injury is important factor
Diagnosis & Treatment Priorities
First: recognize presence of shock or intraabdominal
bleeding
Second: start resuscitative measures for shock /
bleeding
Third: determine if abdomen is source for shock or
bleeding
Fourth: determine if emergency laparotomy is needed
Fifth: complete secondary survey, lab, and radiographic
studies to determine if “occult” abdominal injury is
present
Resuscitation
 Biggest concern
 Positioning for comfort.
 Apply high-flow oxygen.
 Treat for shock.
 An early rapid assessment of the abdomen
 Rectal examination
 Catheters and tubes
 Administer tetanus prophylaxis and antibiotics as
indicated.
Initial Resuscitation
Identify where is the bleeding?
• 4 & On the floor”
 Chest – CXR
 Intraperitoneal abdomen-FAST
 Retroperitoneal abdomen CT scan
 Extremities – (femur #s)-XRs
• Then stop it:
 OR
 Angioembolization
 Pressure
 Reduction & stabilization
Damage control resuscitation
• It’s an alternative resuscitation approach to hemorrhagic
shock which involves:
1. Rapid control of surgical bleeding
2. Early and increased use of red blood cells, plasma and platelets in
a 1:1:1 ratio
3. Limitation of excessive crystalloid use
4. Prevention and treatment of hypothermia, hypocalcemia and
acidosis
5. Permissive hypotension. (Hypotensive resuscitation strategies)
• Damage control resuscitation can be applied to
unstable patients who are with life-threatening
hemorrhage & going to need massive transfusion
Radiological and Ancillary
diagnostic procedures
 Plain x-ray chest,abdomen,and pelvis
 FAST
 Diagnostic peritoneal lavage – Aspiration
 Local Wound Exploration
 Contrast studies, CT scan.
 Urethro-Cysto-graphy
 IVU
 Angiography
Plain films
 Pneumotharax, Haemothorax
 Free air under diaphragm
 Retroperitoneal stippling associated duodenal
injury
 Nasogastric tube, bowel loops in the chest
 Elevation of the both /Single diaphragm
 Lower Ribs # -Liver /Spleen Injury
 In penetrating trauma, injuring trajectory
 Ground Glass Appearance =
Massive Hemoperitoneum
 Obliteration of Psoas Shadow=Retroperitoneal
Bleeding
 Vertebral fracture
XRAY
Focused assessment with
sonography for trauma (FAST)
-To diagnose free intraperitoneal
fluid.
-Evaluate solid organ hematoma
-Four areas:
1. Pericardium (subxiphoid)
space2.Perihepatic & hepato-renal
(Morrison’s pouch)
3.Perisplenic
4.Pelvis (Pouch of
Douglas/rectovesical pouch)
sensitivity 60 to 95% for
detecting 100 mL - 500 mL of
fluid
 (E-FAST):
 Add thoracic windows to look for
pneumothorax. Sensitivity 59%,
specificity up to 99% for PTX
The larger the hemoperitoneum, the
higher the sensitivity. So sensitivity
increases for clinically significant
hemoperitoneum.
How much fluid can FAST detect?
250 cc total
100 cc in Morison’s pouch
CT SCAN
 Accurate for solid visceral lesions and its grading and intraperitoneal
hemorrhage. Guide nonoperative management of solid organ
damage.
 Sensitivity for solid organ is >95% but for enteric & for diaphragmatic 60%
& for pancreatic 30% (organ specific)
 Noninvassive
 Disadvantages : Contrast allergies
INDICATIONS CONTRAINDICATIONS
Blunt trauma
 Hemodynamically stable
patient
Normal or unreliable
physical examination
Clear indication for
exploratory laparotomy
Hemodynamically
unstable patient
Contrast allergic patient
DIAGNOSTIC PERITONEAL LAVAGE
 Useful when USGnot
available
 10ml of blood or enteric
contents (stool,food,
etc.) Constitutes a
positive DPL
 Otherpositivefindings-
• >100,000RBCs/mm3 (penetratingtrauma)
• 500WBCs/mm3
• Amylase175IUand
• detectionof bile,bacteriaorfoodfibers.
Comparison of DPL,FAST and
CT
DPL FAST CT
DOCUMENTS: BLEEDING FLUID ORGAN
BP STATUS: LOW LOW NORMAL
SENSITIVITY: 98% 82% -97% 92%-98%
SPECTIFITY: LOW(MID80) (MID 90) (HIGH 9O)
DISADVANTAGES:Invasive Op. depended Cost & time
Local Wound Exploration
 Formal evaluation of a stab wound under local
anaesthesia in OT
 Penetration of the anterior fascia is considered a
positive LWE
LAPAROSCOPY
 Most useful to evaluate penetrating wounds to
thoracoabdominal region in stable patient
 Spec. For diaphragm injury: sensitivity 87.5%, specificity 100%
 Can repair organs via the laparoscope (diaphragm,
solid viscera, stomach, small bowel.)
 Disadvantages:
 Poor sensitivity for hollow visceral injury and
retroperitoneum
 Complications from trocar misplacement
Exploratory Laparotomy
Indications For Exploratory Laparotomy Are:
• Either…….Clinical
a. Obvious peritoneal signs on physical examination
b. Hypotension with a distended abdomen
c. Abdominal GSW with peritoneal penetration
d. Abdominal stab wound with evisceration, hypotension, or
peritonitis
• Or………Paraclinical
a. Positive FAST with hemodynamic instability or DPL
b. Findings with any other diagnostic intervention (e.g., chest x-
ray [ruptured diaphragm, pneumoperitoneum], abdominal
ultrasound, abdominal CT, or laparoscopy suggestive of
perforation
Damage control
Principles are:
• Control hemorrhage with packing
• Identification of injury
• Prevention and control contamination with
temporary closure
• Avoid further injury
• Resuscitation in the ICU
• Re-exploration and definitive repair once
normal physiology has been restored
WHEN TO INSTITUTE ?
Before:
ER → OR → DEATH
ICU→OR→ICU
APPROACH
Now:
ER→OR D
→CS
Initial Laparotomy In DCS
•Identify the main source of bleeding and stop it
• Perihepatic packing (superior and inferior)
•Small gastrotomies and enterotomies can be rapidly
closed
• Resect non-viable bowel and close the ends
•Minor pancreatic injuries not involving duct- no
treatment
• Distal injury including the panceratic duct- distal
pancreatectomy
• NO pancreaticoduodenectomy (drainage)
• Abdominal closure is rapid and temporary- if there is
any doubt about abdominal compartment syndrome, left it
open (Bogota-bag, vacuum-pack technique, towel clip)
MANAGEMENT OF LIVER
AND SPLENIC TRAUMA
3
5
WSES GRADE OF LIVER
AAST HEMODYNAMIC WSES GRADE
MINOR I-II STABLE I
MODERATE III STABLE II
SEVERE IV-V STABLE III
I-VI UNSTABLE IV
Operative technique/options
• Initial   Explorative Laparotomy
• Temporary control of hemorrhage:
• Why temp?
1. Ongoing hemorrhage, life threatening, no time to
restore circulatory volume.
2. Liver injuries not highest priority.
Initial operative management
• Manual compression
• Temporizing packing
-’’Lap sandwich’’
• Portal occlusion
-’’Pringle maneuver’’
• Total hepatic isolation
• Atriocaval shunt
Operative management option
• Topical agent
• Electrocautery
• Argon beam coagulator
• Hepatorrhaphy
• Hepatectomy
• Non anatomical resection
• Omental patch
• Damage control packing
• Post-operative Angioembolization
• After artery ligation -risk of hepatic necrosis,
bilIoma and abscesses increases
• Portal vein injuries-Primary Repair-ligation to
be avoided
• Liver Packing and a second look or liver
resection are preferable
EARLY
PRINGLE
HEMORRHAGE
IVC HEPATIC VEIN
NO
HEMORRHAGE
HEPATIC
ARTERY
LIGATION
6
2
• Pringle Manure
– Occludes hepatic
artery & portal vein
– If bleed persists, then it
is hepatic venous
bleed
SUTURED LIVER LACERATION
Liver packing and hemostatic fibrin gel on liver
surface
Omental patch
for liver trauma
7
0
Argon
Coagulation
7
1
HepaticResections
Parenchymal tissue fragmentation and skeltonization of vascular-biliary
structures with ultrasonic dissector
Mesh
rapping
* New technique for grade
III,IV laceration,
tamponading large
intrahepatic hematomas
* Not indicated where
juxtacaval or hepatic vein
injury is suspected
Temporary closure
of the abdomen
7
6
7
5
SEVERE INJURY
• Three therapeutic options exist: 1) tamponade
with hepatic packing, 2) direct repair (with or
without vascular isolation), and 3) lobar
resection
• Liver packing is the most successful method of
managing severe venous injuries
When hepatic vascular exclusion is necessary-
shunting procedures to be done
• Veno-veno bypass (femoral vein to axillary or
jugular vein by pass)
• Atrio-caval shunt bypasse (the retro-hepatic
cava blood through the right atrium)
In cases of liver avulsion or total crush injury-
Total hepatic resection+hepatic
transplantation
WSES GRADE OF SPLEEN
AAST HEMODYNAMIC WSES GRADE
MINOR I-II STABLE I
MODERATE III STABLE II
IV-V STABLE III
SEVERE I-V UNSTABLE IV
SPLENORRHAPHY
 Parenchyma saving surgery ofspleen
 Thetechnique isdictated by the magnitude of
the splenicinjury
 Nonbleeding grade I splenic injury may require
no furthertreatment.
 1.Superficial hemostatic strategies like
fibrin glue,gel foam,argon beem
coagulation,diathermy,topical thrombin
 2.Non absorbable suturerepair
 3.Absorbable mesh wrap(polygalactin)
 4.Resectional debridement
SPLENORRHAPHY
SPLENECTOMY
 Indications
-Gr 5injury
-Delayed rupture
-Increasing hematoma
-Clinically unstable of any grade
-Actively bleeding
 Opensplenectomy with midline incision
prefered
AUTOTRANSPLANTATION
 Implanting multiple 1-mm slices of the spleen
in the omentum after splenectomy.
This technique remainsexperimental
and role iscontroversial
EMBOLISATION
 Tc99/sulphur colloid labeled contrast
angiogram to detect vascular damage
 Presenceof extravasation of contrast in
arterial phase (blushsign)
 Pseudo aneurysm pattern needstransarterial
embolisation using polyvinyl
alcohol/silicone/acrylic embolicspheres
 Canbe given to reduceblood loss
preoperatively
SPLENIC ARTERY EMBOLISATION
OPSI
(OVERWHELMING POST SPLENECTOMY
INFECTION)
 Arapidlyfatal infection following removalof
spleen
 Incidence-<1%peryear
 Occurs1stfew yearsaftersplenectomy
 Commonorganisms
• 1.S.Pneumonia
2.H.Influenza
3.N.Meningitis
 Mortality rate-50-80%
 Mechanism-organism with polysaccharide
capsulesneedOPSONIZATION with IGg3or
C3Bwhich attaches tospecial macrophages
found in thespleen
 Post splenectomy patients-lack of
macrophages
SYMPTOMS
 Starts with flu like symptoms
 Meningitis orsepsis
 Rapidly progressive 12-48hrs
OPSI
MANAGEMENT
Prevention-
 Pneumococcal Vaccine(>2Yrs) Administered
Within 24 – 48 HrsAfter Splenectomy
 Meningococcal & H.Influenza Vaccine Only In
EndemicAreas
 Antibiotics- PENICILIN V
• 125mg Bd(<3 Yrs),
• 250mgBd(3-14Yrs),
• 500 Mg Bd (Adults)
THANKYOU

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Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
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MANAGEMENT OF ABDOMINAL TRAUMA

  • 1. Principles Of Trauma Management Abdominal Trauma Hepatobiliary And Splenic Trauma Moderator Prof Vinod Jain Dr. Geetika Nanda Singh Dr.Parijat Suryavanshi Dr.Ashish Chaubey
  • 2. Presentation Statement Unrecognized abdominal and pelvic injuries continue to be A cause of preventable death
  • 4. Classification of injuries  Blunt trauma  Penetrating trauma  Iatrogenic trauma
  • 5. Mechanism of Injury When should you suspect abdominal injury? • Speed • Point of impact • Intrusion • Safety devices • Position • Ejection • Weapon • Distance • Number, location of wounds • Combined mechanism Blunt Penetrating Explosion
  • 6. Blunt Force Mechanism • Spleen • Liver • Small bowel • Pelvis Common Injuries
  • 7. Penetrating Mechanism • Stab • Low energy, lacerations • Gunshot • Ballistics • Type of weapon • Shrapnel • Shotgun • Distance from target • Spread of projectiles • Explosion / blast Any Organ at Risk
  • 8. Case Scenario ● 35-year-old male passenger in high- speed motor vehicle collision ● Blood pressure: 105/80; Pulse: 110; respiratory rate: 18; GCS Score = 15 ● Complaining of pain in Abdomen What injuries do you suspect, and how would you manage this patient?
  • 9. Assessment How do I determine if there is an abdominal injury? Physical Exam • Inspection • Auscultation • Percussion • Palpation Adjuncts of Primary Survey • Pelvic x-ray • C X ray • FAST • DPL
  • 10.  Inspection: abrasions, contusions, lacerations, deformity, entrance and exit wounds to determine path of injury………….. (Grey-Turner, Kehr, Balance, Cullen, seat belt sign….)  Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding  Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum.  Auscultation: bowel sounds may be decreased(late finding). Physical Examination
  • 11. Physical Examination • Accuracy Only 60-65% • Serial Examination- Best Sensitivity And Negative Predictive Value • Primary Objective-rapidly Identify The Patient Who Needs A Laparotomy • Pulse, Blood Pressure, Capillary Refill And Urine Output—hypovolemia + Abdominal Signs • Most important- Peritonitis
  • 12. HOW TO MANAGE SUCH PATIENT?? PRIMARY SURVEY (ABCDE approach,damage control resuscitation,Management of shock) SECONDAY SURVEY (rapid diagnosis and prompt management,damage control surgery) GRADING OF INJURY(AAST GUIDELINE) MANAGEMENT OF SPECIFIC INJURIES AS PER STANDARD PROTOCOL(WSES GUIDELINE)
  • 13. Primary Survey-ATLS Approach  A – Intubation may be required if pt. is in shock, hypotension or unconscious or in need for ventilation  B – Watch for hemo-pneumothorax in both blunt and penetrating thoracoabdominal injuries  C – Start with 1 L crystalloid (If active bleeding you MUST FIND & STOP THE BLEEDING)  D – May see associated thoracolumbar #es  E – Watch for other injuries
  • 14. Secondary Survey History :Not necessary S.A.M.P.L.E S: Symptoms:Pain,vomiting,hematuria,hematochezia, dyspnea, respiratory distress A: Allergies M: Medications L:Last meal E: Events: Mechanism of injury is important factor
  • 15. Diagnosis & Treatment Priorities First: recognize presence of shock or intraabdominal bleeding Second: start resuscitative measures for shock / bleeding Third: determine if abdomen is source for shock or bleeding Fourth: determine if emergency laparotomy is needed Fifth: complete secondary survey, lab, and radiographic studies to determine if “occult” abdominal injury is present
  • 16. Resuscitation  Biggest concern  Positioning for comfort.  Apply high-flow oxygen.  Treat for shock.  An early rapid assessment of the abdomen  Rectal examination  Catheters and tubes  Administer tetanus prophylaxis and antibiotics as indicated.
  • 17. Initial Resuscitation Identify where is the bleeding? • 4 & On the floor”  Chest – CXR  Intraperitoneal abdomen-FAST  Retroperitoneal abdomen CT scan  Extremities – (femur #s)-XRs • Then stop it:  OR  Angioembolization  Pressure  Reduction & stabilization
  • 18. Damage control resuscitation • It’s an alternative resuscitation approach to hemorrhagic shock which involves: 1. Rapid control of surgical bleeding 2. Early and increased use of red blood cells, plasma and platelets in a 1:1:1 ratio 3. Limitation of excessive crystalloid use 4. Prevention and treatment of hypothermia, hypocalcemia and acidosis 5. Permissive hypotension. (Hypotensive resuscitation strategies) • Damage control resuscitation can be applied to unstable patients who are with life-threatening hemorrhage & going to need massive transfusion
  • 19. Radiological and Ancillary diagnostic procedures  Plain x-ray chest,abdomen,and pelvis  FAST  Diagnostic peritoneal lavage – Aspiration  Local Wound Exploration  Contrast studies, CT scan.  Urethro-Cysto-graphy  IVU  Angiography
  • 20. Plain films  Pneumotharax, Haemothorax  Free air under diaphragm  Retroperitoneal stippling associated duodenal injury  Nasogastric tube, bowel loops in the chest  Elevation of the both /Single diaphragm  Lower Ribs # -Liver /Spleen Injury  In penetrating trauma, injuring trajectory  Ground Glass Appearance = Massive Hemoperitoneum  Obliteration of Psoas Shadow=Retroperitoneal Bleeding  Vertebral fracture XRAY
  • 21. Focused assessment with sonography for trauma (FAST) -To diagnose free intraperitoneal fluid. -Evaluate solid organ hematoma -Four areas: 1. Pericardium (subxiphoid) space2.Perihepatic & hepato-renal (Morrison’s pouch) 3.Perisplenic 4.Pelvis (Pouch of Douglas/rectovesical pouch) sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid  (E-FAST):  Add thoracic windows to look for pneumothorax. Sensitivity 59%, specificity up to 99% for PTX The larger the hemoperitoneum, the higher the sensitivity. So sensitivity increases for clinically significant hemoperitoneum. How much fluid can FAST detect? 250 cc total 100 cc in Morison’s pouch
  • 22. CT SCAN  Accurate for solid visceral lesions and its grading and intraperitoneal hemorrhage. Guide nonoperative management of solid organ damage.  Sensitivity for solid organ is >95% but for enteric & for diaphragmatic 60% & for pancreatic 30% (organ specific)  Noninvassive  Disadvantages : Contrast allergies INDICATIONS CONTRAINDICATIONS Blunt trauma  Hemodynamically stable patient Normal or unreliable physical examination Clear indication for exploratory laparotomy Hemodynamically unstable patient Contrast allergic patient
  • 23. DIAGNOSTIC PERITONEAL LAVAGE  Useful when USGnot available  10ml of blood or enteric contents (stool,food, etc.) Constitutes a positive DPL
  • 24.  Otherpositivefindings- • >100,000RBCs/mm3 (penetratingtrauma) • 500WBCs/mm3 • Amylase175IUand • detectionof bile,bacteriaorfoodfibers.
  • 25. Comparison of DPL,FAST and CT DPL FAST CT DOCUMENTS: BLEEDING FLUID ORGAN BP STATUS: LOW LOW NORMAL SENSITIVITY: 98% 82% -97% 92%-98% SPECTIFITY: LOW(MID80) (MID 90) (HIGH 9O) DISADVANTAGES:Invasive Op. depended Cost & time
  • 26. Local Wound Exploration  Formal evaluation of a stab wound under local anaesthesia in OT  Penetration of the anterior fascia is considered a positive LWE
  • 27. LAPAROSCOPY  Most useful to evaluate penetrating wounds to thoracoabdominal region in stable patient  Spec. For diaphragm injury: sensitivity 87.5%, specificity 100%  Can repair organs via the laparoscope (diaphragm, solid viscera, stomach, small bowel.)  Disadvantages:  Poor sensitivity for hollow visceral injury and retroperitoneum  Complications from trocar misplacement
  • 28. Exploratory Laparotomy Indications For Exploratory Laparotomy Are: • Either…….Clinical a. Obvious peritoneal signs on physical examination b. Hypotension with a distended abdomen c. Abdominal GSW with peritoneal penetration d. Abdominal stab wound with evisceration, hypotension, or peritonitis • Or………Paraclinical a. Positive FAST with hemodynamic instability or DPL b. Findings with any other diagnostic intervention (e.g., chest x- ray [ruptured diaphragm, pneumoperitoneum], abdominal ultrasound, abdominal CT, or laparoscopy suggestive of perforation
  • 29. Damage control Principles are: • Control hemorrhage with packing • Identification of injury • Prevention and control contamination with temporary closure • Avoid further injury • Resuscitation in the ICU • Re-exploration and definitive repair once normal physiology has been restored
  • 31. Before: ER → OR → DEATH ICU→OR→ICU APPROACH Now: ER→OR D →CS
  • 32. Initial Laparotomy In DCS •Identify the main source of bleeding and stop it • Perihepatic packing (superior and inferior) •Small gastrotomies and enterotomies can be rapidly closed • Resect non-viable bowel and close the ends •Minor pancreatic injuries not involving duct- no treatment • Distal injury including the panceratic duct- distal pancreatectomy • NO pancreaticoduodenectomy (drainage) • Abdominal closure is rapid and temporary- if there is any doubt about abdominal compartment syndrome, left it open (Bogota-bag, vacuum-pack technique, towel clip)
  • 33. MANAGEMENT OF LIVER AND SPLENIC TRAUMA
  • 34. 3 5
  • 35. WSES GRADE OF LIVER AAST HEMODYNAMIC WSES GRADE MINOR I-II STABLE I MODERATE III STABLE II SEVERE IV-V STABLE III I-VI UNSTABLE IV
  • 36.
  • 37. Operative technique/options • Initial   Explorative Laparotomy • Temporary control of hemorrhage: • Why temp? 1. Ongoing hemorrhage, life threatening, no time to restore circulatory volume. 2. Liver injuries not highest priority.
  • 38. Initial operative management • Manual compression • Temporizing packing -’’Lap sandwich’’ • Portal occlusion -’’Pringle maneuver’’ • Total hepatic isolation • Atriocaval shunt
  • 39. Operative management option • Topical agent • Electrocautery • Argon beam coagulator • Hepatorrhaphy • Hepatectomy • Non anatomical resection • Omental patch • Damage control packing
  • 40. • Post-operative Angioembolization • After artery ligation -risk of hepatic necrosis, bilIoma and abscesses increases • Portal vein injuries-Primary Repair-ligation to be avoided • Liver Packing and a second look or liver resection are preferable
  • 42. 6 2
  • 43.
  • 44. • Pringle Manure – Occludes hepatic artery & portal vein – If bleed persists, then it is hepatic venous bleed
  • 45.
  • 47. Liver packing and hemostatic fibrin gel on liver surface
  • 49. 7 0
  • 51. HepaticResections Parenchymal tissue fragmentation and skeltonization of vascular-biliary structures with ultrasonic dissector
  • 52. Mesh rapping * New technique for grade III,IV laceration, tamponading large intrahepatic hematomas * Not indicated where juxtacaval or hepatic vein injury is suspected
  • 54. 7 5
  • 55. SEVERE INJURY • Three therapeutic options exist: 1) tamponade with hepatic packing, 2) direct repair (with or without vascular isolation), and 3) lobar resection • Liver packing is the most successful method of managing severe venous injuries
  • 56. When hepatic vascular exclusion is necessary- shunting procedures to be done • Veno-veno bypass (femoral vein to axillary or jugular vein by pass) • Atrio-caval shunt bypasse (the retro-hepatic cava blood through the right atrium) In cases of liver avulsion or total crush injury- Total hepatic resection+hepatic transplantation
  • 57. WSES GRADE OF SPLEEN AAST HEMODYNAMIC WSES GRADE MINOR I-II STABLE I MODERATE III STABLE II IV-V STABLE III SEVERE I-V UNSTABLE IV
  • 58.
  • 59. SPLENORRHAPHY  Parenchyma saving surgery ofspleen  Thetechnique isdictated by the magnitude of the splenicinjury  Nonbleeding grade I splenic injury may require no furthertreatment.  1.Superficial hemostatic strategies like fibrin glue,gel foam,argon beem coagulation,diathermy,topical thrombin  2.Non absorbable suturerepair  3.Absorbable mesh wrap(polygalactin)  4.Resectional debridement
  • 61. SPLENECTOMY  Indications -Gr 5injury -Delayed rupture -Increasing hematoma -Clinically unstable of any grade -Actively bleeding  Opensplenectomy with midline incision prefered
  • 62. AUTOTRANSPLANTATION  Implanting multiple 1-mm slices of the spleen in the omentum after splenectomy. This technique remainsexperimental and role iscontroversial
  • 63. EMBOLISATION  Tc99/sulphur colloid labeled contrast angiogram to detect vascular damage  Presenceof extravasation of contrast in arterial phase (blushsign)  Pseudo aneurysm pattern needstransarterial embolisation using polyvinyl alcohol/silicone/acrylic embolicspheres  Canbe given to reduceblood loss preoperatively
  • 65. OPSI (OVERWHELMING POST SPLENECTOMY INFECTION)  Arapidlyfatal infection following removalof spleen  Incidence-<1%peryear  Occurs1stfew yearsaftersplenectomy  Commonorganisms • 1.S.Pneumonia 2.H.Influenza 3.N.Meningitis  Mortality rate-50-80%
  • 66.  Mechanism-organism with polysaccharide capsulesneedOPSONIZATION with IGg3or C3Bwhich attaches tospecial macrophages found in thespleen  Post splenectomy patients-lack of macrophages
  • 67. SYMPTOMS  Starts with flu like symptoms  Meningitis orsepsis  Rapidly progressive 12-48hrs
  • 68. OPSI
  • 69. MANAGEMENT Prevention-  Pneumococcal Vaccine(>2Yrs) Administered Within 24 – 48 HrsAfter Splenectomy  Meningococcal & H.Influenza Vaccine Only In EndemicAreas  Antibiotics- PENICILIN V • 125mg Bd(<3 Yrs), • 250mgBd(3-14Yrs), • 500 Mg Bd (Adults)