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Abd.trauma sri
- 1. Abdominal Trauma Dr.Capt.S.Srinivasan MS.,FAIS.,DMAS., Professor of surgery. MGMC&RI. 20.03.2015 1
- 2. “Golden Hour” Deaths & complications are reduced when trauma victims receive definitive treatment within the 1st hour after injury 20.03.2015 2
- 3. Abdominal trauma Types of injuries: Blunt abdominal injuries Penetrating abdominal injuries 20.03.2015 3
- 4. Types of injury • Blunt injury: 1. Motor Vehicle Accidents 2. Blows 3. Falls from a height 4. Seat belt injuries • “seat belt sign” = highly correlated with intraperitoneal injury 20.03.2015 4
- 5. Penetrating Abd .injuries • Stab Wounds – Knives, ice picks, pens, coat hangers, broken bottles – Liver, small bowel, spleen • Gunshot wounds – small bowel, colon and liver – Often multiple organ injuries, bowel perforations • Blast injuries • Impalement 20.03.2015 5
- 6. Abdominal Trauma • Penetrating Abdominal Trauma – Stabbing 3x more common than firearm wounds – GSW cause 90% of the deaths – Most commonly injured organs: small intestine > colon > liver • Blunt Abdominal Trauma – Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/systems) – Most commonly injured organs: spleen > liver, intestine is the most likely hollow viscus. – Most common causes: MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%) 20.03.2015 6
- 8. Patho physiology of injury Blunt Abdominal Trauma 1.Sudden rise in intra abdominal pressure- Rupture or burst 2. Crushing effect : Compression from crush between solid objects such as the steering wheel / seat belt & the vertebrae 3. Acceleration and deceleration forces- shear injury Shearing causing a tear or rupture from stretching @ points of attachment 20.03.2015 8
- 9. Mechanisms of Injury • Blunt Trauma 20.03.2015 9
- 10. Patho physiology: Penetrating trauma Injury depends on the velocity and proximity of the weapon. Low velocity stab wounds are less destructive Gun shot wounds & other projectiles have high degree of energy ,produce fragmentation and cavitation 20.03.2015 10
- 11. Seatbelt injuries: seat belt sign 20.03.2015 11
- 12. Seat belt injuries Unrestrained front and rear seat passengers are at unequivocally greater risk of intra-abdominal injury than their restrained counterparts. The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries. However, abdominal injuries are still ascribed to shoulder- and lap-belt systems. 20.03.2015 12
- 13. Seatbelt injury • Three point passenger restraint • when used properly, allow kinetic energy transferred by the impact to be absorbed by the bony pelvis and chest. • Diagonal shoulder straps should be worn in combination with lap belts to prevent forward motion of the trunk. • Incorrectly strapped lap belt above ant.iliac crest- compression injuries of the intra abdominal organs & diaphragmatic rupture. • Shoulder strap injuries –carotid artery contusion with or without thrombosis , Clavicle & rib fractures 20.03.2015 13
- 14. Abdominal organs • Solid organs: Liver, spleen, kidneys • Hollow viscus: Stomach,duodenum,small intestine,colon & rectum, • Vascular structures: Aorta,IVC,mesenteric,renal,splenic vessels • Pelvic structures: bladder,rectum, uterus Iliac vessels 20.03.2015 14
- 15. Abdominal Quadrants & Organs 20.03.2015 15
- 16. Abd.trauma: management History: AMPLE Allergies Medications Prior illness or operations Last meal Events and environment surrounding injury 20.03.2015 16
- 17. Abdominal or Pelvic Solid & Hollow Organ Injuries Diagnosis: • Physical examination • Plain x-rays • FAST - Ultrasound • DPL – Diagnostic Peritoneal Lavage • Abdominal, Pelvic CT scan • Retrograde urethrogram • CT cystogram • Angiography 20.03.2015 17
- 18. General Assessment • Bleeding • Pain & abdominal tenderness or guarding • Abdominal rigidity & distension • Evisceration 20.03.2015 18
- 19. Definitions • Cullen’s Sign – Irregular hemorrhagic patches around the umbilicus • Grey Turner Sign – Bilateral flank bruising or ecchymosis. A classic finding of bleeding into the retroperitoneum around the kidneys and pancreas. • Kehr’s Sign – Referred pain in the L shoulder r/t irritation of the adjacent diaphragm • FAST – Focused Assessment with Sonography in Trauma - Identify free fluid (usually blood) in the peritoneal, pericardial, or pleural spaces 20.03.2015 19
- 20. Physical Exam • Generally unreliable due to distracting injury, AMS, spinal cord injury • Look for signs of intraperitoneal injury – abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension – entrance and exit wounds to determine path of injury. – Distention - Pneumoperitoneum, Gastric dilation, or ileus – Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhage – Abdominal contusions – eg lap belts – ↓bowel sounds suggests intra peritoneal injuries – Digital rectal exam 20.03.2015 20
- 21. Physical exam • Rectal exam is important; assess for blood and palpable bony fragments and position of the prostate. High riding prostate suggests posterior urethral tears. • Urethral disruption should be considered when blood is noted at the meatus. • Vaginal exam for bleeding – may suggest bony fragments causing laceration. Implications of bleeding during pregnancy should be considered. 20.03.2015 21
- 22. Lab.tests: • Not very useful • Hct: can be a delayed sign, should do serial. • WBC: in stress, peritoneal irritation • Pancreatic enzymes: if normal, does NOT r/o pancreatic injury amylase: narcotics amylase & lipase: ischemia 2 hypotension both non-specific & non-sensitive for pancreatic injuries 20.03.2015 22
- 23. Imaging • Plain films: – fractures – nearby visceral damage – free intraperitoneal air – Foreign bodies and missiles 20.03.2015 23
- 24. Imaging X-rays: • The 1st & 2nd ribs, sternum, scapula, and Femur are considered to be some of the strongest and least vulnerable bones in the body • Fractures of these bones are indicators of severe trauma 20.03.2015 24
- 25. FAST • Focused assessment with sonography for trauma (FAST) – To diagnose free intraperitoneal blood after blunt trauma – 4 areas: • Perihepatic & hepato-renal space (Morrison’s pouch) • Perisplenic • Pelvis (Pouch of Douglas/rectovesical pouch) • Pericardium (subxiphoid) – sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid 20.03.2015 25
- 26. FAST • Morrison’s pouch (hepato-renal space) 20.03.2015 26
- 28. FAST • Retrovesicle (Pouch of Douglas) • Pericardium (subxiphoid) 20.03.2015 28
- 29. FAST • Advantages: – Portable, fast (<5 min), – No radiation or contrast – Less expensive • Disadvantages – Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. – Limited by obesity, substantial bowel gas, and subcut. air. – Can’t distinguish blood from ascites. – high (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture 20.03.2015 29
- 30. Diagnostic Peritoneal Lavage • 1. attempt to aspirate free peritoneal blood – >10 mL positive for intraperitoneal injury • 2. insert lavage catheter by seldinger, semiopen, or open • 3. lavage the peritoneal cavity with one ltr. Normal saline • Positive test: – In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm3 – WBC count > 5,00-1,000/mm – Presence of bile or particulate matter 20.03.2015 30
- 31. 20.03.2015 31
- 32. 20.03.2015 32
- 33. 20.03.2015 33
- 34. Diagnostic Peritoneal Lavage • Largely replaced by FAST and CT • In blunt trauma, used in pt who is HD unstable and has multiple injuries with an equivocal FAST examination • In stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injury • In GSW, not useful much 20.03.2015 34
- 35. Imaging • CT – Accurate for solid visceral lesions and intra peritoneal hemorrhage – Guide non operative management of solid organ damage – IV contrast only no oral contrast – Disadvantages : – insensitive for injury of the pancreas, diaphragm, small bowel, and mesentery 20.03.2015 35
- 36. Imaging • CT – Able to define organ injury – Good for retroperitoneal & vertebral column – Non-invasive – Not Operator dependant – Not great for hollow viscus – Stable patient – Cost $$$ – Complications: IV or oral contrast • US – Good for solid organs – Portable – Fast – 100 cc detection blood – Mediastinum evaluation – No radiation – No contrast need – Not see well: solid parenchymal, retroperitoneal, diaphragm – Problem if: obesity, gas – Less sensitive than DPL for hemoperitoneal – Operator dependant 20.03.2015 36
- 37. Laparoscopy • Most useful to evaluate penetrating wounds to thoracoabdominal region in stable pt – esp for diaphragm injury: Sens 87.5%, specificity 100% • Can repair organs via the laparoscope – diaphragm, solid viscera, stomach, small bowel. • Disadvantages: – poor sensitivity for hollow visceral injury, retroperitoneum – Complications from trocar misplacement. – If diaphragm injury, PneumoTX during insufflation 20.03.2015 37
- 38. Management of Blunt abdominal trauma • Clinical Indications for Laparotomy after Blunt Trauma MANIFESTATION PITFALL Unstable vital signs with strongly indicated abdominal injury Alternative sources, shock Unequivocal peritoneal irritation (peritonitis) Unreliable Pneumoperitoneum Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy) Evidence of diaphragmatic injury Nonspecific Significant gastrointestinal bleeding Uncommon, unknown accuracy 20.03.2015 38
- 39. Management • General trauma principles: – airway management, 2 large bore IV lines, – cover wounds and eviscerations with sterile dressings • Prophylactic antibiotics: decrease - abdominal sepsis due to intestinal perforation/spillage – (eg Cepoperazone + sulbactam 2 g IV 8 hrly) • In general, leave foreign bodies in and remove in the OR • surgery 20.03.2015 39
- 40. Management: Surgical management: Laparotomy & proceed Definitive surgery Damage control surgery 20.03.2015 40
- 42. 25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar entered at the level of the epigastrium and exited through the left posterior thoracic wall. Abdominal stab wound, with hepatic lesion 20.03.2015 42
- 43. Local Wound Exploration • To determine the depth of penetration in stab wounds • If peritoneum is violated, must do more diagnostics • Prep, extend wound, carefully examine (No blind probing) • Indicated for anterior abdominal stab wounds, less clear for other areas 20.03.2015 43
- 44. Management of penetrating abdominal trauma Mandatory laparotomy vs Selective nonoperative management 20.03.2015 44
- 45. Management of penetrating abdominal trauma • Mandatory laparotomy – Immediate laparotomy indicated for – shock, – evisceration, and – peritonitis – standard of care for all abdominal stab wounds until 1960s, & for GSWs until recently – Now thought unnecessary in 70% of abdominal stab wounds – Increased complication rates, length of stay, costs 20.03.2015 45
- 46. Management of penetrating abdominal trauma • Selective non operative management used to reduce unnecessary laparotomies • Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair • Strategy depends on abdominal region: – Thoracoabdomen • Nipple line to costal margin – Anterior abdomen • Xiphoid to pubis – Flank and back • Posterior to anterior axillary line 20.03.2015 46
- 47. Management of penetrating abdominal trauma Diagnostic evaluation: • Local wound exploration CXR (hemothorax or pneumothorax) Diagnostic peritoneal lavage FAST Thoracoscopy CT 20.03.2015 47
- 48. Penetrating abd.trauma- SNOP • Thoracoabdomen: TRO diaphragmatic injury 7% of thoraco abdominal wounds • Anterior abdomen – Only 50-70% of stab wounds enter the abdomen – of these, only 50-70% cause injury requiring OR • Back/Flank – Risk of retroperitoneal injury – Intraperitoneal organ injury 15-40% 20.03.2015 48
- 49. Penetrating trauma -- In stable pts, CT scan is reliable for excluding significant injury: 1. is immediate lap indicated ? 2. Has peritoneal cavity been violated? 3. Is laparotomy required? 20.03.2015 49
- 50. Management of PAT Gunshot wounds • assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited) 20.03.2015 50
- 51. Management of penetrating abdominal trauma Gunshot wounds • Much higher mortality than stab wounds • Over 90% of pts with peritoneal penetration have injury requiring operative management • Most centers proceed to lap if peritoneal entry is suspected • Expectant management rarely done 20.03.2015 51
- 52. Damage Control • Patients with major exsanguinating injuries may not survive complex procedures • Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair 20.03.2015 52
- 54. Damage Control • 0. initial resuscitation • 1. Control of hemorrhage and contamination – Control injured vasculature, bleeding solid organs – Abdominal packing • 2. back to the ICU for resuscitation – Correction of hypothermia, acidosis, coagulopathy • 3. Definitive repair of injuries • 4. Definitive closure of the abdomen 20.03.2015 54
- 55. Abdominal Compartment Syndrome • Common problem with abdominal trauma • Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure • Primary ACS: associated with injury/disease in abdomen • Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak) 20.03.2015 55
- 56. Abdominal Compartment Syndrome • Effects of elevated IAP – Renal dysfunction – Decreased cardiac output – Increased airway pressures and decreased compliance – Visceral hypoperfusion 20.03.2015 56
- 57. Abdominal Compartment Syndrome • Management – Surgical abdominal decompression – Nonsurgical: paracentesis, NGT, sedation – Staged approach to abdominal repair – Temporary abdominal closure 20.03.2015 57
- 58. Abdominal trauma • Ultrasonography and diagnostic peritoneal aspiration are rapid methods of determining or excluding the presence of hemoperitoneum in the critically ill blunt or penetrating trauma patient. • Clinical indications for laparotomy are more dependable and more frequently applicable to cases of penetrating trauma than cases of blunt trauma. 20.03.2015 58
- 59. Conclusions: • Laparotomy is mandatory • if shock or continued hypotension, evisceration or peritonitis • In HD stable pts Diagnostic studies are used to determine need for laparotomy in PAT and BAT. • FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal blood • Damage Control • is a principle of staged operative management with control and resuscitation prior to definitive repair • Abdominal compartment syndrome is a common problem in abdominal trauma 20.03.2015 59
- 60. ?Questions?
Editor's Notes
- Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
- Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate
- Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures created by outward forces Lap-belt restraints “seat belt sign” = contusion or abrasion across the lower abdomen, highly correlated with intraperitoneal injury
- eg lap belts herald abdominal injuries in one third of cases
- films in which the patient is in a lateral decubitus position, air is located in the superior flank and outlines the lateral liver edge Demonstration of free intraperitoneal air on left lateral decubitus film. This is the preferred decubitus position because it avoids confusion with the gastric bubble and splenic flexure Erect film demonstrates the soap bubble appearance of retroperitoneal air outlining the right kidney. Duodenal perforation is the responsible pathologic condition
- Dependent portions of the intraperiton when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agentseal cavity where blood is likely to accumulate
- Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
- Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
- Figure 43-8. A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate
- Dependent portions of the intraperitoneal cavity where blood is likely to accumulate when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agents Newer studies advocate adding sonographic contrast to further delineate solid organ injuries with minimal hemoperitoneum, especially those of the spleen and liver, which might be amenable to nonoperative management.[64-66] Overall, US can serve as an accurate, rapid, and less expensive diagnostic screening tool than DPL or CT.[67-70]
- Positive test = specific for intraperitoneal injury With lower chest stab wounds, a positive RBC count of 5000 to 10,000/mm3 should be considered as evidence of diaphragmatic injury. Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds
- GSW Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds
- Grade 4 splenic laceration Grade 3 right renal laceration (encircled). CT is particularly helpful in guiding nonoperative management of solid organ damage.[44-46] This includes as-needed follow-up studies of convalescing patients with these injuries. It has also proven effective when incorporated in delayed fashion for patients with decreasing hematocrit, increasing base deficit, or subtle examination changes. By minimizing the incidence of nontherapeutic laparotomies for self-limited injury to the liver or spleen, trauma centers are using CT with intravenous (IV) contrast only, as it has been shown that little additional information is provided by the addition of oral contrast, which delays scanning and may pose an aspiration risk for the patient.[48,49]
- This is considered safest in the event that the implement is intravascular or in a highly vascularized organ.The accuracy of physical examination is limited in cases of blunt and penetrating trauma. It is rendered less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, mental retardation), and spinal cord injury. intestinal perf/spillage can occur afger blunt or PAT Cover anaerobes
- (many do not reach the peritoneum) If LWE indicates that the peritoneum is violated, further diagnostics are indicated. When the stab wound is documented to be superficial to the abdominal cavity, the patient can be safely discharged home after appropriate wound care.[85] Other areas: like back, flank, chest
- DPL The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injury Even a single stab wound to the low chest can violate the mediastinum, thoracic cavity, diaphragm, peritoneal cavity, and retroperitoneum. The risk of diaphragmatic penetration from a left thoracoabdominal stab wound has been measured at 17%.[86] When all thoracoabdominal wounds are considered, the risk of occult injury is 7%.[100] US can be extremely useful in quickly assessing for hemopericardium and hemoperitoneum in the marginally stable patient when thoracotomy or laparotomy is not already clinically indicated.[106] LWE of slash-type wounds may obviate the need for further evaluation. However, the depth of investigation cannot be taken beyond the anterior rib margin to maximize safety and accuracy. Further assessment for intraperitoneal and diaphragmatic injury can be made by DPL. The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injury.[77] Laparoscopy or thoracoscopy can visualize and potentially repair the diaphragm and other organs. Newer multidetector CT and MRI show promise in excluding diaphragmatic injury. CT has a sensitivity of 94% and specificity of almost 96% for detecting diaphragmatic injury. However, equivocal scans must be followed up with more definitive management, including DPL or exploratory laparotomy.[105] A very conservative approach to the left lower chest stab wound, in particular, is mandatory exploration. This approach avoids any opportunity for missed diaphragmatic rents and their delayed consequences but results in an exceptionally high incidence of nontherapeutic operation. Rapid-slice helical CT or MRI may provide a solution to this vexing concern, but data are limited to date.
- Figure 43-11. Abdominal gunshot wound algorithm. *Can be assessed by missile path, plain films, local wound exploration, ultrasonography (US), and laparoscopy (LAP). †Most centers proceed to LAP if peritoneal entry is suspected. ‡Patients with documented superficial and low-velocity injuries can be discharged; unknown-depth or high-velocity injuries require further tests or observation. ?Computed tomography (CT), diagnostic peritoneal lavage (DPL), laparoscopy (LPY), or serial physical examinations (SPEs) can be used in singular or complementary fashion depending on the clinical scenario. ?Expectant management of injuries caused by gunshot wounds is rarely attempted.
- However, the risk of mortality is significantly greater, especially if vascular structures are involved. Missiles striking the low chest commonly penetrate both intrathoracic and abdominal structures, including the diaphragm
- For more extensive abdominal trauma, a central concept is that of damage control
- When would you use the damage control strategy? Essentially if the pt is really sick
- Major complication of abdominal trauma APP = MAP - IAP
- Can lead to significant reduced lung volumes, impaired gas exchange, high ventilatory pressures.