management of retro peritoneal bleeding
TRANSCRIPT
Case Report – History of Fall and Admitted with shock
S.Gobishangar
05/09/2009
Case ReportA 53-year-old well-built man slipped on the
floor and landed on his backHe continued to suffer from sharp abdominal
pains gradually increasing in severity for the following few days
The pain was localized in the epigastrium, left hypochondrium and the back.
As he didn’t bother about his fall, his local doctor attributed these pains to gastritis.
Fourth day following his trauma, he presented to the Casualty Unit with shock and abdominal pain
He could not give relevant history as his level of consciousness continued to deteriorate.
None of his family members who were accompanying him knew about his trauma.
On ExaminationSBP 50-60 mmHgHR 130 bpm. Inspection showed an abdominal mass.Abdominal wall was tender and rigid The mass was fixed and not pulsating
Intensive resuscitation measures started immediately
Blood was taken for cross match and investigationsThe decision of exploration laparotomy was made. The patient was temporary resuscitated, and on the
way to the operating room, he had a rapid CT examination (without contrast)
It was difficult to maintain his vital signs that started to deteriorate again; so he was rushed to theatre.
The CT scan showed a huge multi-locular abdominal cyst with blood-dense fluid inside
The origin of the cyst was not clear due to its sizeCertainly, the possibility of a leaking aortic aneurysm
was excluded. There was no other abnormal finding
At the laparotomy, A huge dark blue cyst was filling most of the
abdominal cavity and pushing the entire bowel to a small compartment
Opening the cyst revealed dark blood clots and altered blood
The cyst was multi-locular as shown on the CT The blood clots were removed and the loculi were
traced down to the retroperitoneal spaceThe retroperitoneal space was full of blood clots of
unidentified origin There was no active bleeding.
The patient by this time received 15 units of blood and 12 units of FFP
The cyst pseudo-wall, which actually was derived from the retroperitoneal wall, was closed by continuous vicryl suture to tamponade the remaining hematoma.
The patient was transferred to the ICUHe stayed there for 3 days and was
transferred to the wardHe was discharged 10 days after his
laparotomy
One month later, a follow-up CT scan showed re-accumulation of some blood clots and mild left hydroureter and hydronephrosis.
The patient was asymptomatic, but to avoid further pressure on his left kidney, he underwent an elective laparotomy.
A smaller multi-locular blood cyst was identified, opened and evacuated and the cyst wall was left open for drainage
The abdomen was closed with two drains inside
The patient went home on the 5th postoperative day
Six months follow up by abdominal ultrasound revealed no back pressure on the left kidney and absence of abdominal cysts or masses
Management of Traumatic Retroperitoneal Bleeding
Types of Retroperitoneal BleedingSpontaneousIotrogenicTraumatic
Blunt traumaPenetrating Trauma
AetiologyCentral retroperitoneum
Avulsion of Small branches from Aorta, IVCSuperior mesenteric arteryPortal vein
Lateal retroperitonumGU (Kidney, Adrenal glands, Ureters, Bladder)
Pelvic retroperitoneumPelvic Fracture sites, Disruption of deep pelvic
artery
Blunt InjuriesCan explain by 3 mechanisms
Rapid deceleration causes differential movement among adjacent structuresThis produces shear forces which causes tear in hollow,
solid, visceral organs and vascular pediclesIntra-abdominal contents are crushed between
anterior abdominal wall and vertebra / posterior thoracic cage
External compression forces causes sudden and dramatic increase in the intra-abdominal pressure.This produces rupture of hollow viscous organ
HistoryDetail history of injury
Mechanism of Injury, Vehicle, SpeedTime of injury
Abdominal traumaUrine colour
ExaminationGeneral examination
HydrationPale, Dyspnoic
CVSLow BP, PR, peripheral pulses
Abdominal examinationDistended abdomenBruising over the abdomenSeat belt marksPenetrating injuryGrey Turner signCullen sign
ChestFlail chest in lower ribsBowel sounds in the chest
Rectal examination BloodAny bony injuries in the pelvis
InvestigationHaematological
HbUS AbdomenCTAngiographyAssess the renal injury
IVU, CT/IVU
TreatmentInitial Primary survey and Resuscitation Urgent Blood transfusionThe non-operative or operative approach
is based on Mechanism of injury Hemodynamic status of the patient and Extent of associated injuries
Therapeutic embolization
Indication for Laparotomy
Persistent haemodynamic instability despite intensive volume replacement
RPB at upper central area after penetrating trauma implies damage to great vessels – Always require urgent exploration
After blunt traumaRetroperitoneal hematomas in the lateral
perirenal and pelvic areas do not require operation and should not be opened if discovered at operation.
Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are opened
Retrohepatic hematomas without obvious active hemorrhage are not opened.
After penetrating trauma
Most retroperitoneal hematomas are opened. Exceptions include isolated lateral perirenal
hematomas & lateral pericolonic haematomasRetrohepatic haematomas without obvious
active hemorrhage are not opened
Bladder InjuryExtra-peritoneal rupture of the bladder
may be managed non-operatively, intra-peritoneal rupture mandates laparotomy.
Damage control surgeryPatients with hemorrhagic or traumatic
shock who have preoperative or develop intra-operative severe metabolic derangements which will adversely affect survival
Stages of “Damage Control” Surgery
1. Limited operation for control of hemorrhage and contamination
2. Resuscitation in the SICU
3. Reoperation
Retroperitoneal Haematoma
Expanding
On Table IVP to assess Contralateral
Kidney
Explore
Not Expanding
Penetrating Trauma
On Table IVP
Explore
Blunt Trauma
Don’t Explore
Investigate Post OP
Follow upRetroperitoneal bleeding patients need
follow upUSS / CT
May need re-evacuation of Haematoma
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