1.Hepatobiliary and Liver Transplant Surgeon ESOT, MESOTGeneral and Laparoscopic Surgeon IMRCS, CABSEmergency medicine Specialist MERC

2. Points Blunt & Penetrating Trauma Approaching FAST diagnostic tool Abdominal Trauma in Children Abdominal Trauma in Pregnancy 3. Outlines Recall ..General facts Recheck ..Up-to-date Review ..Local Practice 4. Introduction One of the leading cause of death and disability. Identification of serious intra-abdominal injuries isoften challenging. Many injuries may not manifest during the initialassessment and treatment period. 5. Epidemiology Peak incidence Abdominal Trauma 15 30 yr . More than 15,000 people die every year as a result ofinjuries by motor vehicle accident, fall. Injury accounts for 10% of all deaths . Estimates indicate that by 2020, 8.4 million people willdie yearly. Prevalence: 13%. 6. Types of Abdominal Trauma Blunt Trauma Penetrating Trauma 7. Blunt Trauma Abdomen 8. Aetiology M.V. Accidents involving high kinetic energy andacceleration or deceleration forces - 60%. Direct blow to abdomen - 15% . Fall- 6-9%. Child Abuse . Domestic Violence . Iatrogenic injury -Endoscopic /Laparoscopicsurgical procedures -Bag-mask ventilations -Inadvertent esophageal intubation -External cardiaccompressions Heimlich maneuver. 9. Prehospital Care The goal of prehospital is to deliver the pt to hospitalfor definitive care as rapidly as possible.Scoop and Run ABC & Care of spinal cord start IV line Communicate to medical control Rapid transport of patient to trauma centre 10. Primary surveyIdentification & treatment of life threatening conditions A irway , with cervical spine precautions B reathing C irculation D isability E xposure 11. Emergency Care Control external bleeding IV fluids Dressing of wounds /Protect eviscerated organs Stabilize an impaled object in place Give high flow oxygen Immobilize the patient with a fractured pelvis Keep the patient warm Analgesics 12. Secondary Survey General & Systemic Examination to identify all occultinjuries. Special attention to Back, Axilla , Perineum PR - sphincter tone ,bleeding ,perforation , high ridingprostate Foleys catheter- monitor urine out-put NG tube 13. Secondary Survey (Contd)AMPLE History A llergy M edications P ast medical history L ast meal E vent - What Happened? 14. Examination Laceration Abrasion Entry/Exit wounds Involvement Chest & Head injury Seat Belt Sign 15. Abdominal wall findings from handlebar injury. 16. Examination (Contd) Cullens Sign : Bluish discoloration around umbilicus Diffusion ofblood along periumbilical tissues or falciform ligamentHemoperitoneum Grey-Turners Sign : Bluish discoloration of the flanksRetroperitonealHematoma hemorrhagic pancreatitis . Kehrs sign : Referred pain, Right shoulder irritation of thediaphragmSplenic injury, free air, intra-abdominal bleeding) Balances Sign : Dullness on percussion of the left upper quadrantRuptured spleen Labia and Scrotum: Pooling of blood from abdominal and pelviccavities. 17. Examination (Contd) Auscultation1. Bowel sounds in the thoracic cavity (Diaphragmaticrupture)2. Haemothorax PalpationMass -Tenderness - Signs of peritonitis - # Ribs -Chest& Pelvic compression test 18. Investigations FAST X-Ray :Chest / Abdomen USG CT-scan Paracentasis Diagnostic Peritoneal Lavage Diagnostic Laparoscopy 19. Focused Assessment withSonography in Trauma (FAST) First used in 1996 Rapid Accurate Sensitivity 86- 99% Can detect 100 mL of blood Cost effective Four different views :Pericardiac - Perihepatic -Perisplenic - Peripelvic spaces Eliminates unnecessary CT scans Helps in management plan 20. Plain X-Ray Chest & Abdomen Pneumotharax Haemothorax Free air under diaphragm Nasogastric tube,Bowel loops in the chest Elevation of the both /Single diaphragm Lower Ribs # Liver /Spleen Injury??? Ground Glass Appearance -Massive Hemoperitoneum Obliteration of Psoas Shadow RetroperitonealBleeding - # vertebra 21. USG Advantage : Easy & Early to Diagnose Noninvasive No Radiation Exposure Resuscitation/Emergency room Used in initial Evaluation Low cost Disadvantage: Examiner Dependent Obesity Gas interposition Low Sensitivity for free fluid less 100 mL False Negative retroperitoneal & Hallow viscus injury 22. Paracentasis Four quadrant aspiration of abdomen Positive tap blood, air, and bile stained fluid Negative tap doesnt rule out injury. False negatives areas high as 22-60%--------NOT Recommended 23. Diagnostic Peritoneal Lavage First described in 1965 Rapid & Accurate test used to identify intra-abdominal injuries Predictive value of greater than 90%The RBC count for lavage fluid is > 1,00,000/cu m.m .WBC count > 500/cu m.m Test is highly sensitive to presence of intraperitoneal blood However specificity is low Indications Unexplained ShockAltered sensorium (Head injury , Drug)General anesthesia for extra-abdominal procedures Contraindications Clear indication for Exploratory LaparotomyRelative - Previous LaparotomyPregnancyObesity 24. CT-scan Gold Standard Haemodynamically Stable Provides excellent imaging of pancreas, duodenum andgenitourinary system Standard for detection of solid organs injury. Determines the source and amount of bleeding Can reveal other associated injuries e.g. High Specificity-95% Contraindication Clear indication for Laparotomy Haemodynamically Unstable Allergy to contrast media 25. Peri -hepatic Free fluid 26. Blunt abdominal trauma with liverlaceration. 27. splenic injury andhemoperitoneum. 28. grade IV splenic laceration fromauto-pedestrian accident 29. DIAGNOSTIC LAPAROSCOPY Haemodynamically stable patients Inadequate/equivocal USG Mild hypotension or persistent tachycardia Persistent abdominal signs/symptoms It decreases non-therapeutic laparotomies Useful in penetrating injury Limitation: Retroperitoneal Injury 30. SURGICALANAGEMENTMaking Decision 31. EAST Algorithm: StableEAST Algorithm: Stable Eastern Association for the Surgery of Trauma, 2001 32. EAST Algorithm: Unstable 33. Anatomic InjuriesThe most commonly injured organsare :the spleen, liver, retroperitoneum,small bowel,, bladder, colorectum,diaphragm, and pancreas.Men tend to be affected slightlymore often than women 34. SPLENIC INJURY Most common intra- abdominal organ to injured (40-55%) 20% of splenic injuries due to left lower rib fractures Success rate of Splenic salvage procedure is 40-60% 35. Liver injury Liver is the largest organ in abdomen 2nd mostcommon organ injured (35-45%) 50% liver injury has stop bleeding spontaneously bythe time of surgery Mortality of liver injury is 10% 36. Pancreatic InjuryRare ---- 10-20% of all abdominal injury Crush Direct blow to abdomen Seat belt injury 37. Renal Injury Presentation: Shock, hematuria & pain Urine: gross or microscopic hematuria Diagnosis:X-ray : KUB IVPUSGCT-scan abdomenRadionuclide Scan The degree of hematuria may not predict the severityof renal injury 38. Diaphragmatic Injury Incidence -0.8%-1.6% in BTA . High index of suspicion required , may be missed. 40 to 50% are diagnosed immediately Presentation may be delayed Imaging Nasogastric tube seen in the thorax Abdominal contents in the thorax Elevated hemidiaphragm (>4 cm Lt vs Rt ) Distortion of diaphragmatic margin. Lt- 69% , Rt -24%B/L- 15% 39. Diaphragm Rupture /Hernia Delayed presentation of post traumatic diaphragmatichernia. 40. Hollow Viscus InjuriesInjuryGastric Penetrating trauma MC Blunt trauma abdomen 1%Crushing Against the Spine -CPR -VigorousVentilation with ET Tube in the Esophagus Heimlich maneuver Diagnosis :X-Ray chest & AbdomenCT scanDiagnostic Peritoneal LavageDuring Surgical Exploration T/t : Expl . Laparotomy with Primary Repair 41. Hollow Viscus InjuriesDuodenum Isolated Duodenum injury rare Incidence - 3-5% Cause Penetrating injury: MC Steering wheel injury Assault Fall Associated with other intra-abdominal injury Diagnosis: Plan X-ray Free air in abdomen Intraoperative diagnosis T/t : Primary Repair 80% caseRoux-en Y duodenojejunostomy 20% 42. Hollow Viscus InjuriesSmall Intestine& Colonic Injuries Commonly Injured in Penetrating injury Blunt Trauma 5% -20%Crush InjuryAt Fixed point DJ & IC Junction T/t : Exploratory Laprotomy 43. Bladder Injury Commonly in BTA 70% of bladder Injury is associated with pelvic fracture. Hematuria Type 1.Extraperitoneal Rupture-by bony fragment Type 2. Intraperitoneal Rupture- at dome when blow indistended bladder Diagnosis Clinical / Cystography T/t:1. Intraperitoneal Trans-peritoneal - closure +SPC2: Extraperitoneal Rupture: Foleys catheter -10 -14 days 44. Ureteral Injury Uncommon Mostly occur after penetrating trauma Associated with concomitant intra-abdominal orgenitourinary injury Diagnosis - IVP -15-20%Retrograde ureteroscopy At the time of Laparotomy T/t : Proximal & mid ureter -End to end Anastomosisover DJ StentDistal Ureteric Reimplantaion 45. Vascular Injury Incidence 5-10% Highly lethal. Associated with extremely rapid rates ofblood loss Exposure is difficult in Laparotomy T/t : Lateral suture ,End to end AnastomosisInterposition graft Mortality rate is very high 46. Penetrating Abdominal Trauma 47. Aetiology In penetrating abdominal trauma due to gunshot wounds, themost commonly injured organs are as follows[1] :Small bowel (50%)Colon (40%)Liver (30%)Abdominal vascular structures (25%) In penetrating abdominal trauma due to stab wounds, themost commonly injured organs are as follows[1] :Liver (40%)Small bowel (30%)Diaphragm (20%)Colon (15%) 48. Penetrating injury to abdomenfrom shotgun wound. 49. Penetrating Trauma Penetrating abdominal trauma has a slightly highermortality rate Second most common cause of abdominal injury Gunshot and stab wounds combine to cause 95% ofpenetrating abdominal injuries. 50. Penetrating abdominal trauma Multiple in 20% of cases Most stab wounds do not cause an intraperitoneal injury A complete exploration is mandatory Abdominal Evisceration Never try to replace organs Cover with moist gauze, then sterile dressing. Transport immediately 51. Gunshot Injury Handguns Rifles Shotgun More dangerous than penetrating injury The degree of injury depends. Amount of kineticenergy imparted by the bullet to the victim Mass of thebullet and the square of its Velocity Injury multiple organ 52. SURGICALANAGEMENTMaking Decision 53. Penetrating abdominal trauma 54. Focused Assessment withSonography in Trauma (FAST) 55. Focused Assessment withSonography in Trauma (FAST)The benefits of the FAST examination include the following: Decreases the time to diagnosis for acute abdominal injury inBAT Helps accurately diagnose hemoperitoneum Helps assess the degree of hemoperitoneum in BAT Is noninvasive Can be integrated into the primary or secondary survey and canbe performed quickly, without removing patients from theclinical arena Can be repeated for serial examinations Is safe in pregnant patients and children, as it requires lessradiation than CT Leads to fewer DPLs; in the proper clinical setting, can lead tofewer CT scans (patients admitted to the trauma service and toreceive serial abdominal examinations)[6] 56. Focused Assessment withSonography in Trauma (FAST)An extended version of the standard FAST examination(E-FAST) has been established and offers additionalinformation.In addition to imaging of the abdomen, the E-FASTexamination includes views of bilateral hemithoraces toassess for hemothorax and views of bilateral upperanterior chest walls to assess for pneumothorax.[7] Forthe remainder of this article, the FAST examination isreferred to as the E-FAST examination, as appropriate. 57. Focused Assessment withSonography in Trauma (FAST)Technique OverviewFocused assessment with sonography for trauma (FAST)shouldinclude views of :(1) the hepatorenal recess (Morison pouch),(2) the perisplenic view,(3) the subxiphoid pericardial window, and(4) the suprapubic window (Douglas pouch).If an extended FAST (E-FAST) examination is performed,views of:(1) the bilateral hemithoraces and(2) the upper anterior chest wall should also be obtained. 58. Probe placement for right upperquadrant laterally. 59. FAST - RUQNormal Morisons Pouch Fluid in Morison pouch 60. Probe placement for left upperquadrant laterally 61. FAST - LUQNormal splenorenal recesss Fluid in splenorenal recess 62. Subxiphoid probe placement. 63. Subxiphoid viewNormal veiw Traumatic tamponade. 64. Suprapubic probe placement. 65. Suprapubic view.Normal View Pelvic Free Fluid 66. Pediatric Abdominal Trauma 67. Pediatric Abdominal Trauma OverviewTrauma is the leading cause of morbidity and mortality in thepediatric population. EtiologyMore than 80% of traumatic abdominal injuries in childrenresult from blunt mechanisms; PrognosisNonoperative treatment of children with blunt abdominaltrauma is successful in more than 95% of appropriatelyselected cases Children with abdominal trauma secondary to assault orabuse have the highest mortality rate 68. Volume management algorithm forpediatric trauma patient. 69. Trauma in PregnancyIncidence- 10-20%Causes : 1.Domestic violence2.Sexual Assault3. Accident 70. Trauma in Pregnancyphysiologic changesMajorAltered anatomical relationshipsSigns and symptoms of injury may be alteredTreatment priorities are the sameUsually the best treatment for the fetus is the besttreatment for the mother70 71. Trauma in PregnancyResuscitation and stabilization may need to be modifiedto accommodate the altered physiologic and anatomicchanges of pregnancy2 patientsConsult OB/GYN earlyDont withhold X-rays (10 rads or more are teratogenic71 72. ImportantsA. Oxygen requirementsB. Blood replacement requirementsC. Proper patient positioningD. Significance of fetal monitoringE. Vaginal bleeding72 73. Primary surveyABCsSupplemental oxygen (re-breather maskIf ventilation is required mild hyperventilationCrystalloid fluid resuscitation and early blood productadministration73 74. Initial assessmentPosition patient to avoid supine hypotension unlessspinal injury is suspectedLeft lateral positioning is preferredIf transport is needed displace uterus to left and elevateright hip74 75. Initial assessment (Contd)Blood is shunted away from the uterus in a hypotensivestateThe gravida can lose up to 35% of her blood volumebefore tachycardia, hypotension, and other signs ofhypovolemia occurThe fetus may be in shock and the mother appear stable75 76. Initial assessment (Contd)With gun shot wounds to the abdomen exploration ismandatoryStab wounds to the abdomen may be able to be observedin selected cases76 77. Secondary AssessmentIf possible place patient on fetal monitor to assessreactivityefetal heart ratcontractions andis required to looksound examany trauma an ultraWithfor placental separation and possibly to obtainbiophysical profile77 78. Secondary Assessment - USGcan be useful for determiningUltrasoundgestation age,placental location,fetal status,amniotic fluid volume,and fetal position78 79. Injury Prevention Speed is a critical factor; a 10% increase speedtranslates into a 40% rise in the case fatality rate. Use of seat belt reduces the risk of death or seriousinjury by 45%. Air Bags reduce the risk of fatal injury by 30% & deathsby 11 %. Children Below 12yrs should be properly restraints inthe back seat. Motorcycle experience death rate 35 time greater thancar. 80. Injury Prevention PrimaryPrevent an injury from its occurrence in the first place:Educational activity such as anti-drink-driving campaigns,speed limit rule -Children should accompanied with parent SecondaryAttempts to lessen the consequences of injury making road& safer car, anti-locking brakes, air bags, helmets, seat belt TertiaryMinimize the effect of injury by health care by individuals &system