23472397 abdominal trauma

8/9/2019 23472397 Abdominal Trauma

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Abdominal TraumaAbdominal Trauma

Dr. Qiu XinguangDr. Qiu Xinguang

Department ofDepartment of General Surgery,General Surgery,

First Affiliated Hospital, Zhengzhou UniversityFirst Affiliated Hospital, Zhengzhou University(450052)(450052)


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Mechanism of InjuryMechanism of Injury

Blunt injuryBlunt injury

Penetrating injuryPenetrating injury

Blast injuryBlast injury Iatrogenic injuryIatrogenic injury


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Blunt injuryBlunt injury

Commonest modeCommonest mode

Frequently multiFrequently multi--system injurysystem injury

Abdominal injury accounts for 10%Abdominal injury accounts for 10%blunt trauma deathblunt trauma death

Road traffic accidentRoad traffic accident


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Mechanism of blunt injuryMechanism of blunt injury

Direct impactDirect impact

Deceleration and rotational forcesDeceleration and rotational forces

Liver and spleen are the mostLiver and spleen are the mostcommonly injured organscommonly injured organs

Bowel injury (acute increase inBowel injury (acute increase in

intraluminal pressure / shearing atintraluminal pressure / shearing atmesentery)mesentery)


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Penetrating injuryPenetrating injury

High velocityHigh velocity

Gunshot woundsGunshot wounds

Low velocityLow velocity

Stab wounds / lowStab wounds / low--velocity missilesvelocity missiles


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Mechanism of penetrating injuryMechanism of penetrating injury

Stab woundsStab wounds

Injury confined to the tract ofInjury confined to the tract ofwoundingwounding


Depends on the energy transferredDepends on the energy transferred

Penetration is accompanied by shockPenetration is accompanied by shockwave with cavitating effect (spiralwave with cavitating effect (spiralpath of motion)path of motion)


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Iatrogenic injuryIatrogenic injury

UncommonUncommon

LaparoscopyLaparoscopy

EndoscopyEndoscopy


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Primary survey and resuscitationPrimary survey and resuscitation

Objectives of this phase:Objectives of this phase:To identify and correct any immediate lifeTo identify and correct any immediate life--threatening conditionsthreatening conditionsTo anticipate problemsTo anticipate problems

The activities are performed simultaneously withThe activities are performed simultaneously withenough personnelenough personnelAA-- Airway and cervical spine controlAirway and cervical spine controlBB-- BreathingBreathingCC-- Circulation with haemorrhage controlCirculation with haemorrhage controlDD-- DisabilityDisabilityEE-- ExposureExposure


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Airway and CAirway and C--spinecontrolspinecontrol

CC--spine injury should be assumedspine injury should be assumed

No attempt should be made to turnNo attempt should be made to turn

the patientthe patients head to one side unlesss head to one side unlessCC--spine injury has been ruled outspine injury has been ruled out

Oxygen provided once airway clearedOxygen provided once airway clearedand securedand secured

Beware of aspirationBeware of aspiration


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BreathingBreathing

Anticipate SIX immediately lifeAnticipate SIX immediately life--threateningthreateningthoracic conditions:thoracic conditions:1. Airway obstruction1. Airway obstruction2. Tension pneumothorax2. Tension pneumothorax

3. Open chest wound3. Open chest wound4. Massive haemothorax4. Massive haemothorax5. Flail chest5. Flail chest6. Cardiac tamponade6. Cardiac tamponade

Respiratory rate and effort are both sensitiveRespiratory rate and effort are both sensitivemarkers of underlying lung pathology (bothmarkers of underlying lung pathology (bothshould be monitored)should be monitored)


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CirculationCirculation

Key objectives of circulatory care:Key objectives of circulatory care:

Stop haemorrhageStop haemorrhageAssess hypovolaemiaAssess hypovolaemia

Vascular assessVascular assess

Appropriate fluid resuscitationAppropriate fluid resuscitation


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Stop haemorrhageStop haemorrhage

Direct pressure (external haemorrhage)Direct pressure (external haemorrhage)

Long bone fractures be splintedLong bone fractures be splinted

Pelvic bindingPelvic binding

Pneumatic antiPneumatic anti--shock garment (PASG)shock garment (PASG)

Pelvic fracture may need external fixationPelvic fracture may need external fixation

Try to avoid:Try to avoid:

Vessel clampingVessel clamping

Tourniquets (distal ischaemia)Tourniquets (distal ischaemia)


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Assessment forhypovolaemiaAssessment forhypovolaemia

Skin (colour, clamminess and capillary refill)Skin (colour, clamminess and capillary refill)

Heart rate and BPHeart rate and BP

Pulse pressurePulse pressure

Conscious levelConscious level ECG monitoringECG monitoring

Search for common sites of occult bleeding:Search for common sites of occult bleeding:

ChestChest

Abdomen / RetroperitoneumAbdomen / Retroperitoneum

PelvisPelvis

Long bonesLong bones

Splints and dressingsSplints and dressings


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VascularassessVascularassess

Large bore IV catheterLarge bore IV catheter

20ml blood taken for grouping and x20ml blood taken for grouping and x--

match and for ematch and for e--

+ full blood count+ full blood count Femoral line / venous cut down /Femoral line / venous cut down /

intraintra--osseous access (if peripheral IVosseous access (if peripheral IVassess failed)assess failed)

Central venous line insertion is notCentral venous line insertion is notessential for initial resuscitationessential for initial resuscitation


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Fluid resuscitationFluid resuscitation

Initial fluid resuscitation:Initial fluid resuscitation:

2L warmed crystalloid2L warmed crystalloid

Responder: Give maintenance fluids onceResponder: Give maintenance fluids once

initial deficit replacedinitial deficit replaced Transient responder: Deteriorate due toTransient responder: Deteriorate due to

continued haemorrhage, give blood andcontinued haemorrhage, give blood andurgent surgical opinionurgent surgical opinion

NonNon--responder: Ongoing haemorrhage atresponder: Ongoing haemorrhage ata greater rate, need urgent surgicala greater rate, need urgent surgicalopinionopinion


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Resuscitation endResuscitation end--pointpoint

Administer sufficient fluids to maintain perfusionAdminister sufficient fluids to maintain perfusionof essential organsof essential organs

SBP 80mmHg (previously normotensive)SBP 80mmHg (previously normotensive) Equivalent to a palpable radial pulseEquivalent to a palpable radial pulse Permissive hypotension to minimizePermissive hypotension to minimize

Ongoing haemorrhageOngoing haemorrhageDisruption of established thrombusDisruption of established thrombusDilution of clotting factorsDilution of clotting factors

Monitored vitals:Monitored vitals:Resp rate, SaO2, HR, BP, Pulse pressure, CardiacResp rate, SaO2, HR, BP, Pulse pressure, Cardiacmonitoring, Temp, Urine output, GCSmonitoring, Temp, Urine output, GCS


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Urethral injuryUrethral injury

Far more common in male patientsFar more common in male patients

55--25% patients with pelvic fractures have an25% patients with pelvic fractures have anassociated urethral injuryassociated urethral injury

Symptoms:Symptoms:

Perineal painPerineal pain

DysuriaDysuria

Failure to voidFailure to void

Signs:Signs:

Blood at urethral meatusBlood at urethral meatus

Bruising around scrotumBruising around scrotum

HighHigh--riding prostateriding prostate


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Urethral injuryUrethral injury

Urinary catheterization isUrinary catheterization iscontraindicated:contraindicated:

Conversion of partial to completeConversion of partial to completetransectiontransection

Stricture formationStricture formation

Introduce infectionIntroduce infection Diagnosis confirmed by retrogradeDiagnosis confirmed by retrograde

urethrogramurethrogram


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DisabilityDisability

Baseline neurological examination:Baseline neurological examination:

AVPU responseAVPU response

Glasgow comma scale (if time permits)Glasgow comma scale (if time permits)

Pupillary responsePupillary response Repeated assessment to look for signs ofRepeated assessment to look for signs of

deteriorationdeterioration

Common causes of deterioration:Common causes of deterioration:

HypoxiaHypoxia

HypovolaemiaHypovolaemia

HypoglycaemiaHypoglycaemia

Raised ICPRaised ICP


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ExposureExposure

Trauma victims must be kept warmTrauma victims must be kept warmand covered with blankets when notand covered with blankets when notexaminedexamined

LogLog--rollroll

Assess the spine from skull base toAssess the spine from skull base tococcyxcoccyx

Examine the back for signs of injuryExamine the back for signs of injury

Rectal examinationRectal examination


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Secondary surveySecondary survey

(abdominal examination)(abdominal examination)

Key objective:Key objective:

To decide if laparotomy is neededTo decide if laparotomy is needed

Detailed examination of the abdomen,Detailed examination of the abdomen,

pelvis and perineumpelvis and perineum Note for bruising and woundsNote for bruising and wounds

Cover exposed bowel loops with warm NSCover exposed bowel loops with warm NSsoaked gauzesoaked gauze

Gastric tube to decompress distendedGastric tube to decompress distendedstomach to facilitate abdominalstomach to facilitate abdominalexamination and reduce risk of aspirationexamination and reduce risk of aspiration


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Physical examinationPhysical examination

Most alert patients will haveMost alert patients will have abdominalabdominaltendernesstenderness

Initial PE in blunt abdominal trauma isInitial PE in blunt abdominal trauma is

only 65% accurateonly 65% accurateAltered mental state (drugs, alcohol, HI,Altered mental state (drugs, alcohol, HI,etc)etc)

Sensory abnormalities (spinal cord injury)Sensory abnormalities (spinal cord injury)

Distracting injuries (extraDistracting injuries (extra--abdominal)abdominal) Serial examinations are often moreSerial examinations are often more

importantimportant


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Physical findingsPhysical findings

DistensionDistension

Usually 2Usually 200 to ileus orto ileus or

pneumoperitoneum orpneumoperitoneum orhaemoperitoneumhaemoperitoneum

BruisingBruising


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PalpationPalpation

Lower ribs fractureLower ribs fracture

Abdominal tenderness, guarding orAbdominal tenderness, guarding orreboundrebound

Pelvic stabilityPelvic stability Lumbar spine for tendernessLumbar spine for tenderness

Rectal examinationRectal examination

Anal toneAnal tone

Prostate position (?high riding)Prostate position (?high riding)

Blood over examination gloveBlood over examination glove


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Plain radiographsPlain radiographs

CXRCXR

The most important plain filmThe most important plain film

Obvious intraObvious intra--thoracic andthoracic anddiaphragmatic injuriesdiaphragmatic injuries

Pelvis (AP view)Pelvis (AP view)

CC--spine (Lat view) make sure Cspine (Lat view) make sure C11--CC77are well shownare well shown

AXR seldom helpful (not routine)AXR seldom helpful (not routine)


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Laboratory studiesLaboratory studies

Laboratory tests play limited role inLaboratory tests play limited role inthe diagnosis of IAI (normal testthe diagnosis of IAI (normal testnever R/O IAI)never R/O IAI)

Baseline Hb levelBaseline Hb level

AcidAcid--base statusbase status

Amylase (not sensitive / specific)Amylase (not sensitive / specific) Urinalysis (gross haematuria is theUrinalysis (gross haematuria is the

most consistent sign of serious renalmost consistent sign of serious renalinjury)injury)


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Diagnostic peritoneal lavageDiagnostic peritoneal lavage

Before the introduction of DPL ~20%Before the introduction of DPL ~20%patient with abdominal trauma died ofpatient with abdominal trauma died ofunrecognized injuryunrecognized injury

Sensitive 97Sensitive 97--99%99% Fast (5Fast (5--15 min)15 min) False +ve 1.4%False +ve 1.4% Complication rate 1%Complication rate 1% No information on retroperitoneal organsNo information on retroperitoneal organs Not sensitive to detect diaphragmatic orNot sensitive to detect diaphragmatic or

bladder injuries (these result in minimalbladder injuries (these result in minimalbleeding)bleeding)


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Contraindication ofPDLContraindication ofPDL

AbsoluteAbsolute

Obvious need for laparotomyObvious need for laparotomy

EviscerationEvisceration RelativeRelative

Pregnancy (>12 wks)Pregnancy (>12 wks)

Previous abdominal surgeryPrevious abdominal surgery


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Criticism ofPDLCriticism ofPDL

Overly sensitiveOverly sensitive

NonNon--bleeding solid organ injuriesbleeding solid organ injuries

(which can be managed(which can be managedconservatively)conservatively)

NonNon--therapeutic laparotomiestherapeutic laparotomies

Best preserved for hypotensive,

Best preserved for hypotensive,unstable, multiunstable, multi--injured patientsinjured patients


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TechniquesTechniques

Closed percutaneousClosed percutaneous

SemiSemi--closedclosed

OpenOpen

1 Liter1 Liter of warmof warm normal salinenormal saline is instilledis instilledin adultsin adults

15 ml/kg in children15 ml/kg in childrenA minimum ofA minimum of300 ml300 ml of lavage fluid mustof lavage fluid mustreturn to give a representative samplereturn to give a representative sample


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Positive results ofDPLPositive results ofDPL

10ml gross blood or bowel contents10ml gross blood or bowel contentswith initial aspirationwith initial aspiration

RBC count >100,000 cells/ml inRBC count >100,000 cells/ml inblunt traumablunt trauma

RBC count >10,000 cells/ml in stabRBC count >10,000 cells/ml in stabwoundswounds

RBC count >5000 cells/ml inRBC count >5000 cells/ml inpenetrating chest traumapenetrating chest trauma

WBC count >500 cells/mlWBC count >500 cells/ml


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UltrasoundUltrasound

Kristensen et al first reported the use ofKristensen et al first reported the use ofUSG in abdominal trauma in 1971USG in abdominal trauma in 1971

NonNon--invasive and inexpensiveinvasive and inexpensive

Portable (bed side)Portable (bed side) No radiation / contrast requiredNo radiation / contrast required Well tolerated (excellent for unstableWell tolerated (excellent for unstable

patients)patients) Quick (within 3 mins in experienced hands)Quick (within 3 mins in experienced hands) Serial examination easy to performSerial examination easy to perform Best screens for haemoperitoneumBest screens for haemoperitoneum


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FAST techniqueFAST technique

Focused Abdomianl Sonography forFocused Abdomianl Sonography forTrauma (Rozycki et al)Trauma (Rozycki et al)

A standard approach which involvesA standard approach which involves

imaging a limited number of US windowsimaging a limited number of US windowsto detect fluid:to detect fluid:

RUQ (MorisonRUQ (Morisons pouch)s pouch)

LUQ (to view the spleen)LUQ (to view the spleen)

Pelvis (Douglas pouch)Pelvis (Douglas pouch)Pericardial window to assess forPericardial window to assess forpericardial effusion (epigastric)pericardial effusion (epigastric)


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Reliability ofFASTReliability ofFAST

Sensitivity 93.4%Sensitivity 93.4%

Specificity 98.7%Specificity 98.7%

Accuracy 97.5%Accuracy 97.5%A collected review of ~5000 patientsA collected review of ~5000 patients(with FAST performed by surgeons)(with FAST performed by surgeons)

Rozycki and Shackford J Trauma 1996; 28: 483Rozycki and Shackford J Trauma 1996; 28: 483--99


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Results interpretationResults interpretation

Unstable patients with a +ve USUnstable patients with a +ve USrequires laparotomyrequires laparotomy

Stable patients can be followed byStable patients can be followed byserial US or employ CT for furtherserial US or employ CT for furtherevaluationevaluation


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LimitationsLimitations

Operator dependentOperator dependent

Uncooperative / agitated patientsUncooperative / agitated patients

ObesityObesity

Surgical emphysemaSurgical emphysema

IleusIleus

Cannot assess retroperitoneal organsCannot assess retroperitoneal organs

Like CT, US is insensitive for bowel injuryLike CT, US is insensitive for bowel injury

Poor sensitivity for penetrating traumaPoor sensitivity for penetrating trauma


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Abdominal computed tomographyAbdominal computed tomography

Introduced in late 1970s for traumaIntroduced in late 1970s for traumamanagementmanagement

CT quantifies intraperitoneal bloodCT quantifies intraperitoneal blood

and grades organ injuryand grades organ injury IV and oral contrastIV and oral contrast

Accuracy is extremely readerAccuracy is extremely reader--

dependentdependent Modern spiral scan requires 3Modern spiral scan requires 3--5 mins5 mins

Dome of diaphragm to pelvisDome of diaphragm to pelvis


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PrecautionsPrecautions

Haemodynamically stableHaemodynamically stable

More time consuming than DPL /More time consuming than DPL /

FASTFAST 3030--50 min50 min

Adequate monitoringAdequate monitoring

Resuscitation facilities must beResuscitation facilities must beavailable in the CT roomavailable in the CT room


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Diagnostic laparoscopyDiagnostic laparoscopy

DL is a relatively new investigationDL is a relatively new investigation Little evidence to support its role in bluntLittle evidence to support its role in blunt

traumatrauma

Not sensitive in Dx hollow viscus andNot sensitive in Dx hollow viscus andretroperitoneal injuryretroperitoneal injury Penetrating trauma (stab wounds) inPenetrating trauma (stab wounds) in

stable patientstable patient100% sensitivity100% sensitivity for identification offor identification of

peritoneal penetrationperitoneal penetration Most effective for diagnosing rupturedMost effective for diagnosing ruptured

diaphragmdiaphragm


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Limitation ofDLLimitation ofDL

Time consumingTime consuming

InvasiveInvasive

General anaestheticGeneral anaesthetic Difficult to exclude hollow viscusDifficult to exclude hollow viscus

perforationperforation


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Management approach forManagement approach for

blunt abdominal traumablunt abdominal trauma Unstable patient with abdominal signUnstable patient with abdominal sign

OperationOperation

Unstable patient with uncertain abdominal injuryUnstable patient with uncertain abdominal injury

DPL or FASTDPL or FAST Stable patient with associated severe injuriesStable patient with associated severe injuries

DPL or FASTDPL or FAST

Stable patient with associated minor injuries andStable patient with associated minor injuries andequivocal abdomenequivocal abdomen

CT scanCT scan Stable patient with abdominal signsStable patient with abdominal signs

CT scan (allowing nonCT scan (allowing non--operative Tx if appropriate)operative Tx if appropriate)


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Penetrates peritoneum in 2/3 casesPenetrates peritoneum in 2/3 cases Only 50Only 50--70% of these have significant70% of these have significant

visceral or vascular injuryvisceral or vascular injury

Selective laparotomies to reduce morbiditySelective laparotomies to reduce morbidityand hospital stay in haemodynamicallyand hospital stay in haemodynamicallystable patientsstable patients

Diagnostic aids:Diagnostic aids:Wound explorationWound exploration

DPLDPLLaparoscopyLaparoscopySerial examinationsSerial examinations


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Lumbarand flank woundsLumbarand flank wounds

Significantly less risk (


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Management approach forManagement approach for

penetrating abdominal traumapenetrating abdominal trauma

Sensitivity ofCT or US are far too low toSensitivity ofCT or US are far too low toexclude intraexclude intra--abdominal injuryabdominal injury


Peritoneal penetrationPeritoneal penetration pp LaparotomyLaparotomyDiagnostic laparoscopyDiagnostic laparoscopy ss LaparotomyLaparotomy

Wound explorationWound exploration ss LaparotomyLaparotomy


Obligatory laparotomyObligatory laparotomy

Diagnostic laparoscopyDiagnostic laparoscopy ss LaparotomyLaparotomy


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Incidence ofIAI requiringIncidence ofIAI requiring

exploratory laparotomyexploratory laparotomy

BluntBlunt%%

PenetratinPenetrating %g %

SpleenSpleen 4747 77LiverLiver 5151 2828

Pancreas /Pancreas /

DuodenumDuodenum

1010 1111

ColonColon 55 2323

Stomach /Stomach /Small bowelSmall bowel

99 4242


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Management PrioritizationManagement Prioritization

Concurrent head injuriesConcurrent head injuries

An exsanguinating abdominal injuryAn exsanguinating abdominal injury

demands a laparotomy to controldemands a laparotomy to controlbleeding before assessment of the HIbleeding before assessment of the HI

Pelvic fracturePelvic fracture

Rapid application of external fixatorRapid application of external fixatorto stabilize the pelvis beforeto stabilize the pelvis beforelaparotomylaparotomy


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NonNon--operative management ofoperative management of

solid organ injurysolid organ injury

Increasing evidence to support nonIncreasing evidence to support non--operative Mxoperative Mx

Parallels with the wideParallels with the wide--spread use ofspread use ofCTCT

Clinical criteria (not CT grading) areClinical criteria (not CT grading) areused for decision makingused for decision making

Must be continuously monitored inMust be continuously monitored inHDU or ICU settingHDU or ICU setting


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Criteria for nonCriteria for non--operativeMxoperativeMx

Solid organ injury shown on CT scanSolid organ injury shown on CT scan

Minimal abdominal signsMinimal abdominal signs

Haemodynamically stableHaemodynamically stable Requires


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Success rate of nonSuccess rate of non--operativeMxoperativeMx

LiverLiver

5050--80%80%

SpleenSpleen93% for minor injuries93% for minor injuries

RenalRenal

Majority can be Mx conservativelyMajority can be Mx conservativelyunless there is injury to renal pedicleunless there is injury to renal pedicleor massive damageor massive damage


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Intervention radiologyIntervention radiology

AngiographyAngiography ss embolizationembolization

Both diagnostic and therapeuticBoth diagnostic and therapeutic

Common useCommon usePelvic fracture with bleedingPelvic fracture with bleedinguncontrolled by fixationuncontrolled by fixation

Solid organ injurySolid organ injury


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Damagecontrol surgeryDamagecontrol surgery

10% trauma patients cannot tolerate10% trauma patients cannot toleratedefinitive procedure at initial laparotomydefinitive procedure at initial laparotomy

Survival benefit demonstrated with theSurvival benefit demonstrated with the

use ofuse ofdamage controldamage control approachapproachControl bleedingControl bleeding

Injured bowel stapled without anastomosisInjured bowel stapled without anastomosis

Solid organ injury packedSolid organ injury packedAbdomen rapidly closed with towel clips orAbdomen rapidly closed with towel clips orplastic bagplastic bag


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Indications for damagecontrolIndications for damagecontrol

HypothermiaHypothermia ee353500CC

Acidosis pH


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Abdominal compartment syndromeAbdominal compartment syndrome

ACS: A group of adverse progressiveACS: A group of adverse progressivephysiological effects of raised intraphysiological effects of raised intra--abdominal pressureabdominal pressure

Abdominal trauma is the commonestAbdominal trauma is the commonestcausecause

Pressure required to precipitate ACSPressure required to precipitate ACS

is unknown (varies with individuals)is unknown (varies with individuals) Most will require decompression atMost will require decompression at

2525--35 cmH35 cmH22OO


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Predisposing factors in traumaPredisposing factors in trauma

patientspatients

Massive intraMassive intra--abdominal bleedingabdominal bleeding

Visceral edema (ischaemiaVisceral edema (ischaemia--

reperfusion)reperfusion) Vigorous fluid resuscitationVigorous fluid resuscitation

SurgerySurgery

PackingPacking


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PathophysiologyPathophysiology

Diaphragmatic splinting (Resp)Diaphragmatic splinting (Resp)

Pressure on IVC (Decreases venousPressure on IVC (Decreases venous

return and thus cardiac output)return and thus cardiac output) Oliguria (Direct renal compressionOliguria (Direct renal compression

+/+/-- reduced systemic blood flow)reduced systemic blood flow)

The condition is fatal unless treatedThe condition is fatal unless treatedbefore irreversible physiologicalbefore irreversible physiologicalinsult occursinsult occurs


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Major systems affectedMajor systems affected

PulmonaryPulmonary

CardiovascularCardiovascular

RenalRenal


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Treatment ofACSTreatment ofACS

Urinary manometry to monitor theUrinary manometry to monitor theintraabdominal pressureintraabdominal pressure

Nasogastric decompressionNasogastric decompression

Abdominal decompressionAbdominal decompression

Control of haemorrhageControl of haemorrhage

Evacuation of gauze packs and bloodEvacuation of gauze packs and blood

Delayed wound closure (temporaryDelayed wound closure (temporaryplastic wrap)plastic wrap)

Ventilatory support till definitiveVentilatory support till definitive

closure (optimally in 2closure (optimally in 2--3 days time)3 days time)


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Thank you!Thank you!


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PhD. Qiu XinguangPhD. Qiu Xinguang

[email protected]@yahoo.com

03710371--6511 57776511 5777

1380371071013803710710

23472397 abdominal trauma

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