abdominal trauma ppt

Abdominal TraumaCheryl Pirozzi, MDFellows Conference 5/4/11

Abdominal TraumaPenetrating Abdominal TraumaStabbing 3x more common than firearm woundsGSW cause 90% of the deathsMost commonly injured organs: small intestine > colon > liver Blunt Abdominal TraumaGreater 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%)

Rosens Emergency Medicine, 7th ed. 2009

Pathophysiology of injuryPenetrating Abdominal TraumaStab Wounds Knives, ice picks, pens, coat hangers, broken bottlesLiver, small bowel, spleenGunshot woundssmall bowel, colon and liverOften multiple organ injuries, bowel perforations


Pathophysiology of injuryRosens Emergency Medicine, 7th ed. 2009

Pathophysiology of injuryBlunt Abdominal TraumaRupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures Crushing effect Acceleration and deceleration forces shear injurySeat belt injuriesseat belt sign = highly correlated with intraperitoneal injury


Physical ExamGenerally unreliable due to distracting injury, AMS, spinal cord injuryLook for signs of intraperitoneal injuryabdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotensionentrance and exit wounds to determine path of injury. Distention - pneumoperitoneum, gastric dilation, or ileusEcchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhageAbdominal contusions eg lap beltsbowel sounds suggests intraperitoneal injuriesDRE: blood or subcutaneous emphysemaRosens Emergency Medicine, 7th ed. 2009

Diagnostic studiesLab tests: not very helpfulMay have Hct, WBC, lactate, LFTs, lipase, tox screenRosens Emergency Medicine, 7th ed. 2009

ImagingPlain films: fractures nearby visceral damagefree intraperitoneal air Foreign bodies and missiles


ImagingCTAccurate for solid visceral lesions and intraperitoneal hemorrhage guide nonoperative management of solid organ damageIV not oral contrastDisadvantages : insensitive for injury of the pancreas, diaphragm, small bowel, and mesenteryRosens Emergency Medicine, 7th ed. 2009

ImagingAngiographyTo embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable ptRarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal traumaRosens Emergency Medicine, 7th ed. 2009

FASTFocused assessment with sonography for trauma (FAST) To diagnose free intraperitoneal blood after blunt trauma4 areas:Perihepatic & hepato-renal space (Morrisons pouch)PerisplenicPelvis (Pouch of Douglas/rectovesical pouch)Pericardium (subxiphoid)sensitivity 60 to 95% for detecting 100mL - 500mL of fluidExtended FAST (E-FAST): Add thoracic windows to look for pneumothorax.Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%)Trauma.orgRosens Emergency Medicine, 7th ed. 2009

FASTMorrisons pouch (hepato-renal space)

trauma.orgRosens Emergency Medicine, 7th ed. 2009

FAST

Perisplenic viewtrauma.orgRosens Emergency Medicine, 7th ed. 2009

FASTRetrovesicle (Pouch of Douglas)

Pericardium (subxiphoid)trauma.orgRosens Emergency Medicine, 7th ed. 2009

FASTAdvantages: Portable, fast (

Diagnostic Peritoneal Lavage Largely replaced by FAST and CTIn blunt trauma, used to triage pt who is HD unstable and has multiple injuries with an equivocal FAST examinationIn stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injuryIn GSW, not used much


Diagnostic Peritoneal Lavage 1. attempt to aspirate free peritoneal blood >10 mL positive for intraperitoneal injury2. insert lavage catheter by seldinger, semiopen, or open3. lavage peritoneal cavity with salinePositive test:In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm3In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm3


Local Wound Exploration To determine the depth of penetration in stab woundsIf peritoneum is violated, must do more diagnosticsPrep, extend wound, carefully examine (No blind probing)Indicated for anterior abdominal stab wounds, less clear for other areas


Laparoscopy Most useful to eval penetrating wounds to thoracoabdominal region in stable ptesp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscopediaphragm, solid viscera, stomach, small bowel. Disadvantages:poor sensitivity for hollow visceral injury, retroperitoneumComplications from trocar misplacement. If diaphragm injury, PTX during insufflationRosens Emergency Medicine, 7th ed. 2009

ManagementGeneral trauma principles: airway management, 2 large bore IVs, cover penetrating wounds and eviscerations with sterile dressingsProphylactic antibiotics: decrease risk of intra-abdominal sepsis due to intestinal perf/spillage(eg zosyn 3.375 g IV)In general, leave foreign bodies in and remove in the ORRosens Emergency Medicine, 7th ed. 2009

Management of penetrating abdominal traumaforsurenot.com

Management of penetrating abdominal traumaMandatory laparotomy vsSelective nonoperative management

Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating abdominal traumaMandatory laparotomy standard of care for abdominal stab wounds until 1960s, for GSWs until recentlyNow thought unnecessary in 70% of abdominal stab woundsIncreased complication rates, length of stay, costsImmediate laparotomy indicated for shock, evisceration, and peritonitis


Management of penetrating abdominal traumaSelective management used to reduce unnecessary laparotomies Diagnostic studies to determine if there is intraperitoneal injury requiring operative repairStrategy depends on abdominal region:ThoracoabdomenNipple line to costal marginAnterior abdomenXiphoid to pubisFlank and backPosterior to anterior axillary line


Management of penetrating abdominal traumaThoracoabdomenBig concern is diaphragmatic injury7% of thoracoabdominal woundsDiagnostic evaluation:CXR (hemothorax or pneumothorax)Diagnostic peritoneal lavageFASTThoracoscopy


ThoracoabdomenBiffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating abdominal traumaAnterior abdomenOnly 50-70% of anterior stab wounds enter the abdomenof these, only 50-70% cause injury requiring OR1. is immediate lap indicated ?2. Has peritoneal cavity been violated?3. Is laparotomy required?Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of PATAnterior abdomenRosens Emergency Medicine 7th ed

Management of penetrating abdominal traumaBack/FlankRisk of retroperitoneal injuryIntraperitoneal organ injury 15-40%Difficulty evaluating retroperitoneal organs with exam and FASTIn stable pts, CT scan is reliable for excluding significant injury:Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617

Management of penetrating abdominal traumaGunshot woundsMuch higher mortality than stab woundsOver 90% of pts with peritoneal penetration have injury requiring operative managementMost centers proceed to lap if peritoneal entry is suspectedExpectant management rarely doneBiffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617Rosens Emergency Medicine 2009

Management of PATGunshot woundsassess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited) Rosens Emergency Medicine, 7th ed. 2009

Management of Blunt abdominal trauma

ashwinearl.blogspot.com

Management of Blunt abdominal traumaExam less reliableDiagnostic studies to determine if there is hemoperitoneum or organ injury requiring surgical repairFAST, CT, DPLIn HD stable pts, CT is preferred


Management of Blunt abdominal traumaClinical Indications for Laparotomy after Blunt Trauma


MANIFESTATIONPITFALLUnstable vital signs with strongly indicated abdominal injuryAlternative sources, shockUnequivocal peritoneal irritationUnreliablePneumoperitoneumInsensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy)Evidence of diaphragmatic injuryNonspecificSignificant gastrointestinal bleedingUncommon, unknown accuracy

Damage ControlPatients with major exsanguinating injuries may not survive complex proceduresControl hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repairWaibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage Control0. initial resuscitation1. Control of hemorrhage and contaminationControl injured vasculature, bleeding solid organsAbdominal packing2. back to the ICU for resuscitationCorrection of hypothermia, acidosis, coagulopathy3. Definitive repair of injuries4. Definitive closure of the abdomenWaibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage ControlWaibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage ControlResuscitation in the ICUIVF (crystalloid, not colloid)Transfusion?1:1:1 PRBC/plt/FFPRecombinant activated factor VIIIncreased thromboembolic complicationsRewarming if hypothermicCorrection of metabolic abnormalitiesLow tidal volume ventilation recommended (4-6 ml/kg)Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Damage ControlOpen abdominal wounds and definitive closure40-70% cant have primary closure after definitive repair. Temporary closure methods

Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430

Abdominal Compartment SyndromeCommon problem with abdominal traumaDefinition: elevated intraabdominal pressure (IAP) of 20 mm Hg, with single or multiple organ system failure APP below 50 mm Hg Primary ACS: associated with injury/disease in abdomenSecondary (medical) ACS: due to problems outside the abdomen (eg sepsis, capillary leak)Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Abdominal Compartment SyndromeBailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:2329

Abdominal Compartment SyndromeEffects of elevated IAPRenal dysfunctionDecreased cardiac outputIncreased airway pressures and decreased compliance Visceral hypoperfusionSugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338

Abdominal Compartment SyndromeManagementSurgical abdominal decompressionNonsurgical: paracentesis, NGT, sedationStaged approach to abdominal repairTemporary abdominal closureSugrue M. Curr Opin Crit Care 2005; 11:333-338Bailey J. Crit Care 2000, 4:2329

ConclusionsWatch out for implements and missiles violating the abdomenLaparotomy is mandatory if shock, evisceration, or peritonitisDiagnostic studies used to determine need for laparotomy in PAT and BATFAST is noninvasive, quick and accurate way to evaluate for intraperitoneal bloodDamage Control is a principle of staged operative management with control and resuscitation prior to definitive repairAbdominal compartment syndrome is a common problem in abdominal trauma

ReferencesBiffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617 Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit Care Med. 2010 Sep;38(9 Suppl):S421-30.Marx: Rosens Emergency Medicine, 7th ed. 2009 MosbySugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:2329

*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*Grade 4 splenic lacerationGrade 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] *Angioembolization of splenic laceration. Note coil in the splenic artery (white arrow) and blush representing active hemorrhage stemming from two branches*Dependent portions of the intraperitonwhen 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 accumulatewhen 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 agentsNewer 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]*GSW Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds*Positive test = specific for intraperitoneal injuryWith 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*(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**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 PATCover anaerobes*****DPL The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injuryEven 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.

**Due to low incidence of intraperitoneal injuries, selective management is well acceptedAsk these 3 questions algorithmImmed lap for Hemodynamic compromise, peritoneal signs, evisceration,

*Clinical mandate = shock, evisceration, peritonitis**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*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.****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**These are all big topics, about general ICU management but management in the ICU involves:The best transfusion protocol is debated..11.2010 NEJM eval of off-label, prospective clinical trials -> increased arterial thromboembolic complications with rfviiLow tidal volume ventilation- extrapolation from ards studiesCritical care med 2004 retrospective cohort study- found association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome

*The best transfusion protocol is debated..Low tidal volume ventilation

*Major complication of abdominal traumaAPP = MAP - IAP*Can lead to significant reduced lung volumes, impaired gas exchange, high ventilatory pressures. **

abdominal trauma ppt

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