trauma abdominal penetrante
TRANSCRIPT
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TRAUMA ABDOMINAL TRAUMA ABDOMINAL PENETRANTEPENETRANTE
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REGIONREGIONABDOMINALABDOMINAL
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
GENEROGENERO
90%90% 10%10%
60%60% 40%40%CerradoCerrado
AbiertoAbierto
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
EDADEDAD
TRAUMA CERRADOTRAUMA CERRADO 38 años 38 años
TRAUMA PENETRANTETRAUMA PENETRANTE 26 a26 añosños
! CADA VEZ MAS JOVENES !! CADA VEZ MAS JOVENES !
ICML Y CF
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
MECANISMO DE LESION Y ORGANO COMPROMETIDO
Penetrante (n=1272) Cerrado (n=539)Penetrante (n=1272) Cerrado (n=539)
HIGADO 357 (28 %) 275 (51%)(51%)
BAZO 94 (7%) 251 (47%)(47%)
COLON 296 (23%)(23%) 29 (5%)
INTESTINO DELGADO 369 (29%)(29%) 37 (7%)
ESTOMAGO 168 (13%) 10 (2%)
DUODENO 69 (5%) 20 (4%)
PANCREAS 79 (6%) 31 (6%)
TRAUMA MATTOX 2000
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0 5 10 15 20 25 30
BAZO
HIGADO
RIÑON
I. DELGADO
COLON
Penetrante
Cerrado
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
MECANISMO DE LESION Y ORGANO COMPROMETIDOMECANISMO DE LESION Y ORGANO COMPROMETIDO
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HUVHUV
PENETRANTE : 89%PENETRANTE : 89%
CERRADO : 11%CERRADO : 11%
Garcia,Sarmiento 1990 HUV
MECANISMO DE LESION Y RATA DE LAPAROTOMIAS
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
NUMERO DE ORGANOS COMPROMETIDOS VS SUPERVIVENCIA
No deOrganos No deLesionados Pacientes Supervivientes
1 74 73 (98.6%)
3 59 52 (88.1%) 4 35 25 (71.4%)
5 15 10 (66.7%)
7 4 1 (25%)
9 1 0 (0.0%)
Feliciano.Ann of surgery 1988;208:362-370
Arma de fuegoArma de fuego
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CORTOPUNZANTECORTOPUNZANTE
CARGA MULTIPLECARGA MULTIPLE
ALTA VELOCIDADALTA VELOCIDAD
ARMAS CORTASARMAS CORTAS
TRAUMA PENETRANTETRAUMA PENETRANTE
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
ASOCIACION AMERICANA DE CIRUJANOSASOCIACION AMERICANA DE CIRUJANOS V REUNION V REUNION Abril de 1885Abril de 1885
Tobias Richarson: 33 pacientes heridos por A.F.33 pacientes heridos por A.F.
13 RECUPERARON SIN CIRUGIA
20 OPERADOS TODOS MURIERON
ANNALS OF SUGERY,2001; 234: 395
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II GUERRA MUNDIALII GUERRA MUNDIAL
Jarvis3 1946 Laparotomia MandatoriaLaparotomia Mandatoria
Wolff1 1955 333 10% 7,2%Rob2 1947 560 12% 29,0%
Autor AAutor Año ño No Lap (-) Mort. Lap(-) No Lap (-) Mort. Lap(-)
1. General Surgery 1955; 2;89 Surgery inWordl War II2. Surg,Gynec,and Obst 1947 85;147.Diagnosis of abdominal trauma3. Surg,Gynec,and Obst 1946;82:174.Experience in the Manegement of the abdominal Wound of warfare
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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Trauma penetrante
LAPAROTOMIA
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
ARMA CORTOPUNZANTEARMA CORTOPUNZANTE
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
Indications for Operation in Abdominal Trauma Gerald W. Shaftan, M.D., Brooklin,New York
180 69% - 1%
No Manejo no Qx MortalidadNo Manejo no Qx Mortalidad
American Journal of Surgery, 1960 ;99:657-664
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X2=27.23 p<.001Acta Med Valle 1976; 7: 97
HUV XI 1972-X,1973
Laparotomía Rutinaria Vs Selectiva
RutinariaAntes XI,73RutinariaAntes XI,73
SelectivaDespues XI,73SelectivaDespues XI,73
LAPAROTOMIALAPAROTOMIA NN NO TNO T
(+)(+) (-)(-)
131
155
286
131
155
286
46
8
54
46
8
54
177
163
340
177
163
340
26%
5%
26%
5%
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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010
2030
4050
60
7080
90100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 HORASHORAS
TRAUMA ABDOMINAL POR A.C.P.TRAUMA ABDOMINAL POR A.C.P.
N=49/118N=49/118
APARICION DE SIGNOSAPARICION DE SIGNOS
QUIROZ,GARCIA 1995
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TRAUMA ABDOMINALPOR A.C.P.TRAUMA ABDOMINALPOR A.C.P.TRAUMA ABDOMINALPOR A.C.P.TRAUMA ABDOMINALPOR A.C.P.
CLINICA Y NECESIDAD DE CIRUGIACLINICA Y NECESIDAD DE CIRUGIACLINICA Y NECESIDAD DE CIRUGIACLINICA Y NECESIDAD DE CIRUGIA
CLINICA
(+)
(-)
CLINICA
(+)
(-)
LAPAROTOMIATERAPEUTICALAPAROTOMIATERAPEUTICA
SI
47
0
SI
47
0
NO
8
63
NO
8
63
SENSIBILIDADSENSIBILIDAD 100%100%
ESPECIFICIDADESPECIFICIDAD 89%89%
V. P. POSITIVOV. P. POSITIVO 86%86%
V.P. NEGATIVO V.P. NEGATIVO 100%100%
Quiroz F, García A. Enviado a J TraumaQuiroz F, García A. Enviado a J Trauma
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TRAUMA ABDOMINAL por ACPTRAUMA ABDOMINAL por ACP
Adv Surg 1987; 20: 1-16Adv Surg 1987; 20: 1-16
OBSERVACIONOBSERVACION
EXAMEN (+)541 PTESEXAMEN (+)541 PTES EXPLORACIONEXPLORACION
CASACASA
(+)293(+)293
(-)248(-)248
(+) 47.1%(+) 47.1%
(+) 52.9%(+) 52.9%
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TRAUMA ABDOMINALTRAUMA ABDOMINAL
Surg Clin NA 1999; 79: 1331Surg Clin NA 1999; 79: 1331
PENETRANTE O DUDOSA
PENETRANTE O DUDOSA
EXPLORACION DE LA HERIDA
EXPLORACION DE LA HERIDA
OBSERVACIONOBSERVACION
P.ANTITETANICASALIDA
P.ANTITETANICASALIDANO PENETRANO PENETRA
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
Fascia transversalisFascia transversalis
EXPLORACION HERIDA TRAUMATICAEXPLORACION HERIDA TRAUMATICA
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EXPLORACION HERIDA TRAUMATICAEXPLORACION HERIDA TRAUMATICA
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EPIPLOCELEEPIPLOCELE
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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EPIPLOCELEEPIPLOCELE
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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EPIPLOCELEEPIPLOCELETRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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EPIPLOCELEEPIPLOCELE
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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EVISCERACION TRAUMATICAEVISCERACION TRAUMATICA
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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EVISCERACION TRAUMATICAEVISCERACION TRAUMATICA
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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..
HERIDA POR ALMARADAHERIDA POR ALMARADA
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
= = PENETRANTEPENETRANTE
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ARMA DE FUEGOARMA DE FUEGO
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
ARMA DE FUEGOARMA DE FUEGO
• Onda cavitacional• Alta energia• Trayectos erraticos• Laparotomia (-) poca morbilidad• Examen fisico es poco fiable
LAPAROTOMIA MANDATORIALAPAROTOMIA MANDATORIA
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
! Una Laparotomia no se le niega a nadie ! ! Una Laparotomia no se le niega a nadie !
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Laparotomía NegativaLaparotomía NegativaMorbilidadMorbilidad
NN
J Trauma 1995; 38: 54Am J Surg 1988; 156: 544Br J Surg 1984; 71: 92J Trauma 1981; 21: 298SGO 1979; 148: 23Acta Med Valle 1975; 6:1
J Trauma 1995; 38: 54Am J Surg 1988; 156: 544Br J Surg 1984; 71: 92J Trauma 1981; 21: 298SGO 1979; 148: 23Acta Med Valle 1975; 6:1
%%
172
217
1138109
684
172
217
1138109
684
2122181317 7
2122181317 7
Publicacion
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Numerosos pacientes heridos esperando ser operados
HUV Unidad de trauma Cali, Colombia.
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HISTORIA NATURALHISTORIA NATURAL
TRAUMA ABDOMINAL POR BALATRAUMA ABDOMINAL POR BALA
T.A.x A.F. T.A.x A.F. n=309n=309
CIRUGIACIRUGIATARDIATARDIA
SISI
SISI
CIRUGIACIRUGIAINMEDIATAINMEDIATA
106106
203203
NONO
NONO
14149292
OBSERVACIONOBSERVACION
Arch Surg 1997; 132: 178Arch Surg 1997; 132: 178
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MANEJO SELECTIVO HDA AF ABDOMENMANEJO SELECTIVO HDA AF ABDOMEN
TIEMPO TRAUMA - INDICACION QX
TIEMPO TRAUMA - INDICACION QX
< 1 hora
1 hora
3 horas
> 4 horas
No aplica
< 1 hora
1 hora
3 horas
> 4 horas
No aplica
123123 Terapéutica 101No terap 22Terapéutica 101No terap 22
60
31
15
17
54 (31%)
60
31
15
17
54 (31%)
N= 177N= 177
,Garcia,Baptiste 1999
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MANEJO SELECTIVO HDA AF ABDOMENMANEJO SELECTIVO HDA AF ABDOMENMANEJO SELECTIVO HDA AF ABDOMENMANEJO SELECTIVO HDA AF ABDOMEN
HERIDAS ABDOMINALES POR HERIDAS ABDOMINALES POR ARMA DE FUEGOARMA DE FUEGO
HERIDAS ABDOMINALES POR HERIDAS ABDOMINALES POR ARMA DE FUEGOARMA DE FUEGO
EXAMEN FISICOEXAMEN FISICO Sensibilidad 100 %Sensibilidad 100 % Especificidad 63 %Especificidad 63 %
VPP 83 %VPP 83 % VPN 100 %VPN 100 %
GARCIA,BAPTISTE, 1999
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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MANEJO SELECTIVOMANEJO SELECTIVOTRAUMA ABDOMINAL POR BALATRAUMA ABDOMINAL POR BALA
AÑOAÑO
19601960
19781978
19901990
19911991
19971997
19991999
20012001
AUTORAUTOR
SHAFTAN G.SHAFTAN G.11
McALVANAH J.McALVANAH J.22
MOUKART D.T.MOUKART D.T.33
DEMETRIADES D.DEMETRIADES D.44
DEMETRIADES D.DEMETRIADES D.55
GARCIA A.GARCIA A.6 6
VELMAHOS GVELMAHOS G.7.7
NN
99
221221
111111
146146
309309
177177
18561856
NO CXNO CX
(%)(%)
4545
4646
2020
2323
2929
3131
3838
Am J SurgAm J Surg11 1960; 99: 657 1960; 99: 657 J TraumaJ Trauma22 1978; 18: 203 1978; 18: 203 Br J SurgBr J Surg3 3 1990; 77: 652 1990; 77: 652 Br J SurgBr J Surg44 1991; 78: 220 1991; 78: 220 Arch SurgArch Surg55 1997; 132: 178 1997; 132: 178 HuvHuv6 6 1999 1999 Ann SurgAnn Surg7 7 2001; 234: 395 2001; 234: 395
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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NONONONOLaparotomía Rutinaria
Laparotomía Rutinaria
Ferrada HUV
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EVALUACION PRIMARIAEVALUACION PRIMARIA
TRAUMA PENETRANTE ABDOMINALTRAUMA PENETRANTE ABDOMINAL
A,B,C,D,E.A,B,C,D,E.MORIBUNDOMORIBUNDO
INESTABLEINESTABLE
ESTABLEESTABLE
MORIBUNDOMORIBUNDO
INESTABLEINESTABLE
ESTABLEESTABLE
Garcia HUV
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
PROTOCOLO DE OBSERVACIONPROTOCOLO DE OBSERVACION
CADA HORA, POR 24 HORASCADA HORA, POR 24 HORAS
SIGNOS VITALESSIGNOS VITALES
EXAMEN ABDOMINALEXAMEN ABDOMINAL
DESPUES DE 12 HORAS: V.O.DESPUES DE 12 HORAS: V.O.
CADA HORA, POR 24 HORASCADA HORA, POR 24 HORAS
SIGNOS VITALESSIGNOS VITALES
EXAMEN ABDOMINALEXAMEN ABDOMINAL
DESPUES DE 12 HORAS: V.O.DESPUES DE 12 HORAS: V.O.
Garcia HUV
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•ABDOMEN DUDOSOABDOMEN DUDOSO
•SECCION MEDULARSECCION MEDULAR
•T.C.E.T.C.E.
•INTOXICACION SEVERAINTOXICACION SEVERA
•ABDOMEN DUDOSOABDOMEN DUDOSO
•SECCION MEDULARSECCION MEDULAR
•T.C.E.T.C.E.
•INTOXICACION SEVERAINTOXICACION SEVERA
ABDOMEN NO VALORABLEABDOMEN NO VALORABLE
LPDLPDLAPAROSCOPIALAPAROSCOPIACATCATLAPAROTOMIALAPAROTOMIA
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. . .. .. .
... . . ....
. .. . . .
.. . ......
. . . . .. .. . .
..
.. . .. .
.
.
HERIDA DE CARGA MULTIPLEHERIDA DE CARGA MULTIPLE
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
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HERIDA DE CARGA MULTIPLEHERIDA DE CARGA MULTIPLE
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
Menos de 2,7 MetrosMenos de 2,7 Metros laparotomialaparotomia
Mas de 6,3 MetrosMas de 6,3 Metros ObservacionObservacion
FERRADA,Clin. Qui. NorteAmer.1999;6:1326
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TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE
SHOCKABDOMEN (+)HEMATEMESISRECTORRAGIAEVISCERADO
ESTABLEABDOMEN (-)
LAPAROTOMIA SALIDA
EXPLORACION HERIDA
OBSERVACION 24 Horas
PENETRA NO PENETRA
(-)(+)
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HUV Cali,ColombiaHUV Cali,Colombia
TRAUMA ABDOMINAL PENETRANTETRAUMA ABDOMINAL PENETRANTE