16.abdominal injury yarsa
DESCRIPTION
ATRANSCRIPT
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Abdominal Trauma
Dr JOKO PURNOMO SpB(K)Onk
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• Trauma Abdomen merupakan kelainan yang sering menyebabkan kematian bila tidak mendapat penanganan tepat
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Objectives
1 Anatomi abdomen 2 Kecurigaan terhadap trauma abdomen dari
mekanisme trauma3 Penegakan diagnosis4 Penanganan gawat darurat5 Rujukan pasien
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Epidemiology
• Trauma pada abdomen dibagi 2 tumpul dan tembus disini kelainan utama pada trauma yg menyebabkan kematian dan kesakitan
• pada trauma tumpul limpa dan liver adalah organ yg paling sering terkena dengan angka kematian 8.5%.
• Luka tembus lebih sering meninggal diatas 12% dan 1/3 dari semua trauma abdomen
• 90% dari luka tembus disebabkan tembakan maupun luka tusuk.
• Sering pada perkotaan.• Laki2 > wanita
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Abdomen
• Depan dari interkosta 4 (garis transnipple pada laki2) ligamentum inguinal dan
symphysis pubis, garis anterior axilla
• flank area dari interkosta 6 tulang iliac, antara garis axilla anterior & posterior.
• Belakang ujung dari scapula, iliac crest, antara garis axilla posterior.
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Kecurigaan trauma Abdomen
• Trauma tumpul– Kecepatan, titik hantaman, – adanya intrusi, alat keamanan, – posisi, ejeksi• Trauma tembus– Jenis senjata – jumlah – arah dan jarak• Ledakan- Trauma campuran
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Organ apa yg paling sering terkena pada trauma tumpul?
1 Limpa (40% to 55%),
2 liver (35% to 45%),
3 Dan usus (5% to 10%)
4 Organ lain..
5 Pelvis
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Mekanisme dari Trauma
• Kompresi : tumbukan langsung ke liver atau tekanan ke usus
• Krushing: tumbukan langsung pada epigastrium menghancurkan organ
diatas spine, pangkreas/ usus
• Tarikan : pada sabuk pengaman yang tidak sesuai peletakan.
• Adanya Airbag tidak mencegah adanya trauma
• Sabuk pengaman tiga titik lebih baik dari 2 titik,
• Pada perdarah karena truma tumpul
abdomen mungkin tidak memerlukan operasi
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Pattern of Injury in Blunt Abdominal Trauma
Spleen 40.6% Colorectal 3.5%
Liver 18.9% Diaphragm 3.1%
Retroperitoneum 9.3% Pancreas 1.6%
Small Bowel 7.2% Duodenum 1.4%
Kidneys 6.3% Stomach 1.3%
Bladder 5.7% Biliary Tract 1.1%
* Rosen: Emergency Medicine (1998)
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Trauma Tembus :Penetrating
● Tusukan● energy rendah , lacerasi luas
● Tembak● transfer Kinetic energy
kavitasi, berguling kecepatan, ukuran,
pantulan, pecahan, benda asing dll
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Cedera organ yang paling sering terkena:
Luka tusuk dan luka tembak kecepatan rendah / tinggi
Luka tusuk
hati (40%) usus halus (30%)diafragma (20%)usus besar (15%)
Luka tembak
usus halus (50%), usus besar (40%), hati (30%), vaskuler (35%)
Trauma Penetrans
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PENILAIAN
Riwayat trauma
Tumpul : kecepatan, jenis benda, posisi korban pasca trauma dan kerusakan kendaraan akibat trauma.
Penetrans : jenis senjata dan jarak.
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PEMERIKSAAN FISIK
Inspeksi
Auskultasi
Perkusi
Palpasi
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Definitions
• Cullen’s Sign – Irregular hemorrhagic bercak sekitar umbilicus
• Grey Turner Sign – Bilateral lecet / ecchymosis pada flank. Temuan klassic dari bleeding di retroperitoneum sekitar kidneys dan pancreas.
• Kehr’s Sign – nyeri alih pada bahu kiri r/t irritasi diaphragm
• FAST – Focused Assessment with Sonography in Trauma - Identify free fluid (usually blood) in the peritoneal, pericardial, or pleural spaces
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Pemeriksaan luka → eksplorasi oleh dokter bedah.
Menilai stabilitas tulang pelvis.
Pemeriksaan perineal, rektal dan penis.
Pemeriksaan vaginal dan gluteal.
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Mempengaruhi pmx
• Alkohol obat lain• Cedra kepala cedara medula spinalis• Usia, • Cedera pada spinal ata kosta
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Management
• Diagnosis awal dan resusitasi. • Penegakan adanya trauma abdomen lebih penting
dari pada diagnosis pasti• Pemeriksaan awal dan resusitasi harus simultan• Prinsip ABC harus dijaga mempertahankan
airway,breathing saat menangani shock• Tetap mencari trauma yg lain
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• Monitori Tensi, frekwensi nadi , saturasi oxygen.
• Resusitasi cairan awal 2 liter kristaloid• Tentukan repon penderita• Transient respond dan non respon segera
laparotomy.
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PEMASANGAN KATETER
Pemasangan NGT dan kateter urin sering dilakukan sebagai bagian dari tahapan resusitasi.
Kontra indikasi pemasangan NGT→fraktur basis kranii.
Pemasangan kateter urine: • Monitor produk urin• dekompresi v. urinaria sebelum DPL• Diagnosis
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Kontraindikasi kateter
• Adanya ruptur urethra– Meatal bleeding– Retensi urin – Prostat melayang– RT mencari darah, pecahan tulang, TMSA
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Laboratory
• Jangan menunggu hasil lab• Tidak stabil minta tipe cross tes pembekuan
darah• Kehamilan • Alkohol• Perdarahan
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PEMERIKSAAN RADIOLOGIS
RutinPemeriksaan ronsen stdanar ATLS:
- foto servikal lateral - toraks AP - pelvis AP
Tambahan - foto abdomen AP - kontras
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X ray
• Tumpul– Ap thorax dan pelvis
• Tembus– Ap thorax / abdomen dengan marker
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DIAGNOSTIK KHUSUS
Trauma tumpul DPL (Diagnostic Peritoneal Lavage) USG CT scan
Trauma penetrans Anterior → eksplorasi luka Posterior → foto ronsen + kontras.
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Kontras
• Vesika Urinaria• Ginjal• Urethra• Git
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MODALITAS DIAGNOSTIK
I. FASTII. DIAGNOSTIC PERITONEAL LAVAGE
(DPL) III. ABDOMINAL CT - SCANIV. LAPAROSCOPY
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DPL VS ULTRASOUND VS CT SCAN PADA TRAUMA TUMPUL
DPL USG CT SCAN
Indikasi
Menentukan adanya perdarahan bila BP
Menentukan cairan bila BP
Menentukan organ cedera bila BP normal
Keuntungan
Diagnosis cepat dan sensitif; akurasi 98%
Diagnosis cepat; tidak invasif dan dapat diulang; akurasi 86%-97%
Paling spesifik untuk cedera; akurasi 92%-98%
Kerugian
Invasif, gagal mengetahui cedera diafragma atau cedera retroperitoneum
Tergantung operator distorsi gas usus dan udara dibawah kulit. Gagal mengetahui cedera diafragma usus, pankreas
Membutuhkan biaya & waktu tang lebih lama, tidak mengetahui cedera diafragma, usus dan pankreas
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Penegakan diagnosis
Trauma tembus dengan vs stabil• Thorak bawah
– Pmx serial, laparoskopi, ct scan• Abdomen depan
– DPL, eksplorasi, Pmx serial • Punggun
– kontras, dpl, Pmx serial
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aAbdominal traumabaaado
Gun shotGun shot
Stab wound
Blunt abdominal
trauma
Mdanatory laparotomy
Evisceration ,positive DPL, Haemodynamic instabilty,peritonitis
Stable ; FAST,CTScan,DPL
Unstable haemodynamically
LAPAROTOMY
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INDIKASI OPERASI
A. Indikasi berdasarkan evaluasi abdomen
1. Trauma tumpul abdomen dengan DPL + USG + 2. Trauma tumpul abdomen dengan hipotensi berulang
setelah resusitasi cairan3. Peritonitis difusa4. Hipotensi dengan luka tembus5. Perdarahan dari gaster, anus, tr.ur inarius akibat luka
tembus6. Luka tembak melalui rongga peritonium atau
retroperitonium7. Eviscerasi
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A.Indikasi berdasarkan pemeriksaan ronsen
1. Udara bebas, udara retroperitoneal atau ruptur diafragma akibat trauma tumpul
2. CT scan + kontras memperlihatkan perforasi organ berongga akibat trauma tumpul dan penetrans
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Penetrating Abdominal Trauma
Luka yg terlihat tidak mencerminkan tingkat keparahan cedera
Kemungkinan perdarahan signifikan
Kemungkinan terkena usus
Pasien mungkin syok
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Impalement Injury
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Impalement Injuries
DO NOT REMOVE OBJECT OR EXERT ANY FORCE UPON IT!
Perdarahan hebat dpt menyebabkan syok
Periksa denyut distal di tempat luka tusuk
Imobilisasi objeknya
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Evisceration
Extrusion of abdominal contents secondary to penetrating abdominal trauma
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Manajemen Evisceration Injuries
Gunakan balutan steril utk menempatkan organ yg keluar di dekat luka (TIDAK ke dlm luka)
Tutup organ & luka sepenuhnya dgn balutan lembab & steril
JANGAN buat TEKANAN KE LUKA atau ORGAN YG KELUAR
Ikatan yg longgar disekitar luka
Persiapkan utk pembedahan
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MASALAH KHUSUS
Diafragma Robekan trauma tumpul lebih sering
hemidiafragma kiri, besar robekan 5-10 cm, posterolateral
Duodenum Robekan pada duodenum terjadi pada
pengendara bermotor yang tidak menggunakan sabuk pengaman dan tabrakan frontal.
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Pankreas Cedera pankreas paling sering akibat trauma
langsung di epigastrium yang menekan ke tulang belakang.
CT scan + kontras mungkin tidak menunjukkan tdana trauma pankreas yang berarti bila dilakukan segera setelah cedera.
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TRAUMA PELVIS
Trauma pelvis biasanya akibat tabrakan mobil dan pejalan kaki,sepeda motor.
Fraktur pelvis mempunyai hubungan erat dengan cedera pada struktur intraperitoneal dan retroperitoneal serta struktur vaskular
Mekanisme trauma kompresi AP, kompresi lateral atau vertikal.
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PENILAIAN TRAUMA PELVIS
Inspeksi
Palpasi tulang pelvis
Palpasi prostat
Perbedaan / diskripensi tungkai bawah, posisi eksternal rotasi
Nyeri pada palpasi tulang pelvis
Pemeriksaan ronsen pelvis AP
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PENANGANAN FRAKTUR PELVIS
Resusitasi
Immobilisasi tulang pelvis dengan PASG/pelvic sling/gurita
Kontrol perdarahan interne dengan operasi
Fiksasi eksterna
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KESIMPULAN
Resusitasi ABCDE
Trauma abdomen di bawa ke RS diperlukan konsultasi dini dengan dokter bedah
Trauma abdomen dibagi trauma tumpul dan trauma tajam
Pengelolaan trauma tumpul dan trauma tajam berdasarkan pemeriksan fisik & pemeriksaan khusus.
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Secondary survey
• History of incident.• Physical examination of the exposed patient.• Examination of anterior dan posterior abdomen.• Palapte for tenderness ,guarding dan rebound tenderness.• Percussion dan auscultation.• Rectal examination.• Perineal examination.• Insert NG tube dan urethral catheter.
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Assessment: History
AMPLE Mechanism MVC:
Speed Type of collision (frontal, lateral,
sideswipe, rear, rollover) Vehicle intrusion into passenger
compartment Types of restraints Deployment of air bag Patient's position in vehicle
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A.M.P.L.E. - a simple mnemonic for keyinformation
• A: allergies (e.g. penicillin or aspirin)• M: medication (e.g. a beta-blocker or warfarin)• P: previous medical history (e.g. previous surgery or
anaesthetic mishap)• L: last mealtime (i.e. drink versus major meal)• E: events surrounding the incident (e.g. fell 5 metres
with immediate loss of consciousness)• Examine each body region meticulously
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A missed abdominal injury can cause a preventable death.
Abdominal Injury
Factors that Compromise the Exam
● Alcohol dan other drugs● Injury to brain, spinal cord● Injury to ribs, spine, pelvis
Caution
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Decision Making
• Airway• Breathing• Circulation
Hemodynamically
StableHemodynamically
UnstableTransientResponder
S H O C K
How are you going to assess?
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Decision Making
• Stable patient• CT Scan• Operative
– Solid organ injury, hypotensive– Hollow viscus organ injury– Intraperitoneal bladder injury– Diaphragmatic injury
• Non-operative management– Observation– Interventional Radiology
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Options for Management
Laparotomy Hemodynamic Stability?
Diffuse Abdominal Tenderness
Yes No
Indications for Laparotomy – Penetrating Trauma
● Hemodynamically abnormal● Peritonitis● Evisceration● Positive DPL, FAST, or CT● Violation of peritoneum
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Options for Management
• Hemodynamically stable penetrating injurySerial ObservationWound ExplorationDPLCT scan +/- ContrastLaparoscopyLaparotomyUltrasound/echo – cardiac boxPericardial window – cardiac box
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Investigations
In haemodynamically stable patients.• Full blood count dan haematocrit.• Urea dan electrolytes.• FAST; Focused Abdominal Sonography for
Trauma- detects free fluid in the peritoneal cavity. Non invasive dan rapid. 88% sensitive,99% specific dan 97% accurate.
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Focused Abdominal Sonography for Trauma (FAST)Demonstrate presence of free intraperitoneal
fluidEvaluate solid organ hematomasAdvantagesNo risk from contrast media or radiationRapid results, portability, non-invasive, ability to repeat
exams.
DisadvantagesCannot assess hollow visceral perforationOperator dependentRetroperitoneal structures are not visualized
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FAST• Four View Technique:
– Morrison’s pouch (hepatorenal)– Douglas pouch (retropelvic)– Left upper quadrant (splenic view)– Epigastric (View pericardium)
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Diagnostic peritoneal lavage
• 98% sensitive in detecting intra abdominal bleeding.
• Does not detect diaphragmatic injuries.• Poor at detecting retroperitoneal bleed.• Invasive procedure.• Contraindicated in patients with prevoius
surgery,pregnancy.
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Objective criteria for assessing DPL
• Positive criteria; blood in chest tube or urethral catheter. > 10 mls blood on opening abdomen.RBC count >100,000/ul. WBC count > 500/ul. Amylase > 175U/ml.presence of fecal matter or bile.
• Equivocal criteria; RBC count 50,000 -100,000( in penetrating trauma 25,000 – 50,000). WBC count 100 -500/ul. Amylase 75 – 175 U/ml.
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• Negative criteria; RBC count < 50,000/ul ( in penetrating trauma <25,000). WBC count < 100/ul.Amylase < 75U/ml.
• Interpretation.;laparotomy if there is a positive criteria. Reassess or consult if the results are equivocal or repeat lavage in 2 hours. Or do US/CT Scan.
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Contraindications of DPLAbsolute :
PeritonitisInjured diaphragmExtraluminal air by x-raySignificant intraabdominal injury by CT scanIntraperitoneal perforation of the bladder by cystography
Relative :Previous abdominal operations (because of adhesions)Morbid obesityGravid UterusAdvanced cirrhosis (because of portal hypertension dan the risk of
bleeding)Preexisting coagulopathy
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CT Scan
• Replacing DPL.• 98% sensitive in detecting intraperitoneal bleeding.• Contrast enhanced CT Scan gives useful anatomical
dan fuctional information on organs.• Can identify organ injuries dan be used to
determine which injuries can be managed conservatively in stable patients.
• Useful in grading solid organ injuries(liver dan spleen)..
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Laparoscopy
• Increasingly used in assessing trauma.• Useful in determining peritoneal penetration
dan identifying diaphragmatic injuries.• Also can be used for treating certain injuries.
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Mangement
Principles of management are; • Stop haemorrhage. • Debride devitalised tissues. • Repair injured bowel by suturing or
resection.• Eliminate foreign bodies/contamination dan
intestinal contents.
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Preoperative preparation
• Immediate surgery once significant injury is confirmed or in haemodynamically unstable patients.
• Broad spectrum antibiotics to cover both aerobic dan anerobic organisms.
• Investigations dan clinical findings should guide management in stable blunt injury patients.
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Management cont`d
• Blunt abdominal trauma.• Initial assessment dan resuscitation;
Haemodynamically stable or unstable.• Haemodynamically stable dan no peritonitis,
negative DPL, negative FAST, Negative CTScan – observation dan serial examinations.
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• Haemodynamically unstable; Laparotomy.• Positive DPL – Laparotomy• Intra-peritoneal fIuid seen on FAST –
Laparotomy.• CT Scan findings of solid viscus ( liver
/spleen) injury - grade of injury
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Indications for Laparotomy – Blunt Trauma
● Hemodynamically abnormal with suspected abdominal injury (DPL / FAST)
● Free air
● Diaphragmatic rupture
● Peritonitis
● Positive CT
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• THANK YOU
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Liver
• The liver, is the most vulnerable abdominal organ to blunt injury because of its size dan location.
• Injured in about 5% patients admitted for trauma. • Also vulnerable to penetrating trauma.• Liver injuries present a serious risk for shock because the
liver tissue is delicate dan has a large blood supply dan capacity. Injuries include laceration or contusion, a hematoma may develop. Injury may be associated with bile leak dan biliary peritonitis.
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Spleen
• Spleen is the commonest injured organ in blunt abdominal trauma.
• Fractures of the left lower ribs are associated with spleen lacerations in 20 % of cases.
• Most splenic injuries can be managed conservatively after grading with CT Scan.
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Grade 1 SPLENIC INJURY
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Grade 3 injury
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Splenic injury
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Bowel
• The small intestines takes up a large part of the abdomen dan is likely to be damaged in penetrating injury.
• The bowel may be perforated.Gas within the abdominal cavity seen on plain abdominal X-Ray or CT is diagnostic.
• Bowel injury may be associated with complications such as infection, abscess, bowel obstruction, dan the formation of a fistula.
• Bowel perforation requires surgery.
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Perforated viscus
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Stab wound with evisceration
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Management
• Splenic dan liver injuries grade 1,2 dan 3 may be treated conservatively.
• Grade IV dan V – Laparotomy. Evisceration -laparotomy
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Thank you