6.Abdominal trauma.pdf

Abdominal Trauma Dr. Sherko Abbas Nadir General surgeon and laparoscopic surgeon Lecturer –college of medicine \HMU M.B.Ch.B F.K.B.M.S  Etiology —Penetrating Trauma —Blunt trauma  Penetrating Trauma —Stab Wound —Gun Shot Injury —Blast Injuries  Blu...

Abdominal Trauma Dr. Sherko Abbas Nadir General surgeon and laparoscopic surgeon Lecturer –college of medicine \HMU M.B.Ch.B F.K.B.M.S  Etiology —Penetrating Trauma —Blunt trauma  Penetrating Trauma —Stab Wound —Gun Shot Injury —Blast Injuries  Blunt Trauma — Road Traffic Accidents ( MVA) — Fall From Height( FFH) — Crush Injuries — Sport Injuries — Violence  Anatomical Consideration Abdomen can be divided in 4 areas - Intra thoracic abdomen - True abdomen - Pelvic abdomen - Retroperitoneal abdomen  Intra thoracic abdomen — Diaphragm — Liver — Spleen — Stomach — Transverse colon  True abdomen — Small bowel — Ascending colon — Descending colon — Sigmoid colon  Pelvic abdomen — rectum — bladder — iliac vessels — (in women) internal reproductive organs.  Retroperitoneum — posterior to peritoneal lining of abdomen. — Abdominal aorta, — IVC — most of duodenum, pancreas — kidneys, ureters & posterior aspects of ascending & descending colon  Mechanisms of injury — Acceleration &Deceleration injuries: eg: FFH,MVA — Differential movements of fixed & nonfixed structures (e.g. liver & spleen lacerates at sites of supporting ligaments). — Compression, crush, or sheer injuries: Eg; entrapment injury to abdominal viscera ! deformation of solid or hollow organs, rupture (e.g. small & large bowel, gravid uterus)  Common injury patterns — In patients undergoing laparotomy for blunt trauma, most frequently injured organs are — spleen (40-55%) — liver (35-45%) — small bowel (5-10%). (ATLS, 2008) — Patients undergoing laparotomy for GSW ,the most commonly involved organ are — Small bowel — Large bowel — Liver — Vascular structure Duodenum: — Classically, frontal-impact MVA with unrestrained driver or direct blow to abdomen. — Bloody gastric aspirate — Retroperitoneal air on XR or CT — Confirmed with upper GI series or double contrast CT  Small bowel injury: — Generally from sudden deceleration with subsequent The seat belt sign is a clinical finding characterized by tearing near fixed points of bruising or abrasions across the abdomen, chest, or neck in the shape of a seat belt after a motor vehicle accident. This sign raises concern for attachment. — Often associated with seat belt underlying injuries, especially internal abdominal trauma, including bowel, mesenteric, or lumbar spine injuries. The presence of the seat sign, lumbar distraction fracture belt sign often warrants further investigation with imaging (CT scan) (Chance fracture) — DPL superior to FAST or CT for and close observation, as it can indicate significant internal damage. diagnosis. A Chance fracture is a type of spinal injury that involves a horizontal fracture through the vertebra, affecting the vertebral body, pedicles, and spinous processes. It typically occurs in the thoracolumbar spine (T12-L2) region. This injury is most commonly caused by a flexion-distraction mechanism, often seen in car accidents where the lap belt acts as a fulcrum (e.g., seat belt injury). Clinical Features: Severe back pain Potential neurological deficits if the spinal cord is involved It requires urgent medical evaluation and often surgical intervention. Pancrease — Direct epigastric blow compressing pancreas against vertebral column. — Early normal serum amylase does NOT exclude major pancreatic trauma. — CT with PO/IV contrast – NOT particularly sensitive in immediate post-injury period. Diaphragm: — Penetrating injury: any penetrating injury below the nipple should raise the possiblity of diaphragmatic injury with abdominal viscera — In penetrating trauma the defect is small & could be multiple — Blunt injury: any blunt trauma to the abdomen & pelvis — In blunt trauma the defect is large (5-10 cm) involving the posterolateral aspect of the left hemidiaphragm — The whole stomach ,spleen &transverse colon might herniate to the chest — The injury most commonly missed in blunt trauma Diagnosis : — There is no single standard investigation for the diagnosis — Most diaphragmatic injury is silent & the presenting feature are those of injury to the surrounding organs eg:spleen,stomach..etc — CXR: blurred or elevated hemidiaphragm, hemothorax, GT in chest. Video-assisted thoracoscopic surgery — The most accurate evaluation is by VATS,or laparoscopy Treatments — In penetrating trauma is laparotomy, to exclude any hollow viscus injury — Solid organ injury — Laceration to liver, spleen, or kidney — Injury to one of these three + hemodynamic instability: considered indication for urgent laparotomy — Isolated solid organ injury in hemodynamically stable patient: can often be managed nonoperatively. Pelvic fractures: Suggest major force applied to patient. Usually auto-pedestrian, MVC, or motorcycle Significant association with intraperitoneal and retroperitoneal organs and vascular structures. Management  PRIMARY SURVEY A : Airway with cervical spine protection. B : Breathing & oxygenation. C : Circulation & control external bleeding. D : Disability or neurological status. E : Exposure (undress) & Environment (temp. control). 29 1/00  Initial Management Trauma Protocol.Immobilize Cervical spine.100% oxygen.Wide bore I.V line.Blood samples.Crystalloid infusion.Trauma series X-ray -Chest , cervical spine, pelvis Abdominal Trauma: Examination — Inspection:- — Abdominal distension — Movement of Abdominal wall — Record all external marks of injury(seat belt sign, cullen sign & grey turner sign…..) — Record entry & exit site of bullet injury — Evisceration.  Examination (cont) Palpation:- Look for — Tenderness/rigidity/guarding — Pelvic compression test &compression of lower chest wall — DRE — Spine tenderness  Examination (cont) —Percussion: Look for free fluid —Auscultation Bowel sounds (Controversial advantage in trauma setting)  Physical Exam: — Grey-Turner sign: — Bluish discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancreas, kidney, or pelvic fracture. — Cullen sign: — Bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage. — Kehr sign: — Left shoulder pain while supine; caused by diaphragmatic irritation (splenic injury, free air, intra-abd bleeding) — Balance sign: — Dull percussion in LUQ. Sign of splenic injury; blood accumulating in subcapsular or extracapsular spleen.  Investigations Lab investigations:- — FBC — Serum Amylase estimation — Urinalysis — Other routine lab test for base line (BUN) Radiological Investigations — CXR for fracture ribs & free gas under diaphragm — PXR (Diagnostic Peritoneal Lavage( DPL The main advantage is that it can confirm or exclude presence of inrtaperitoneal bleeding. Indication: 1. Unconscious patient 2. Patients with high energy transfer with equivocal physical signs 3. Multiple injury with unexplained shock 4. Pts. With spinal cord injury 5. Intoxicated Pts. 6. Pts. with suspected abdominal injury undergoing surgery for other condition Contraindication — Previous abdominal surgery(relative) — Pregnancy — obesity — Patient with obvious surgical abdomen(absolute)  Procedure: — LA (containing adrenaline) is advisable — Open or closed (Seldinger); infraumbilical, but may be supraumbilical in pelvic #s or advanced pregnancy. — P.D. catheter is used & inserted to peritoneal cavity.  DPL +ve DPL — Free aspiration of blood (> 10 mL) — GIT contents or bile in Hemodynamically abnormal pt: indication for laparotomy — (If -ve) , perform lavage with 1000 mL warmed R\L. — Allow to mix, compress abdomen and logroll paient, then sent to lab. — (+VE test): — >100,000 RBC/mm3, — >500 WBC/mm3, — Gram stain with bacteria. — Amylase >200 units.  DPL -Limitations — False + ve in 20% of cases mainly in pelvic # — Does not differentiate between solid organ & hollow viscus injuries …?? — 98% Sensitive but not specific — Not helpful in retroperitoneal injury  Ultra sonography (FAST) — FAST means ??? — To evaluate presence of haemoperitoneum in blunt abdominal trauma  FAST —Positive FAST in unstable trauma patients indicates the need for laparotomy without any further tests. —Negative FAST means source of bleed is from other than abdomen  FAST Advantages: — Fast, Rapid & Cheap — Non invasive, no radiation — Can be performed at bed side — No need to shift patient to radiology  FAST:- Limitations — Obesity — Gas interposition — Subcutaneous emphysema — Operator dependent  CT abdomen — Indicated in haemodynamically stable patients — To identify & grade solid organ injuries — To diagnose retroperitoneal injuries — To follow patients of solid organ injuries treated conservatively  CT abdomen- draw backs — Expensive — Requires transfere to Radiology Department — Low sensitivity to diagnose bowel or diaphragmatic injuries  Diagnostic laparoscopy — To identify peritoneal violation in anterior or flank stab wounds — To identify diaphragmatic injuries  Management — Conservative —Operative Conservative management by observation —Haemodynamically stable — blunt abdominal trauma — mild to moderate grade of solid organ injuries —Hollow viscous injuries must have been ruled out(FAST )  Conservative Management — Managed in ICU — Blood grouped & cross matched — OT is alerted — Monitoring by Vital parameters, serial U/S & CT Scan — Exploration needed if 1. clinical or radiological deterioration 2. > 4 units blood transfusion in 24 Operative Management — Laparotomy indicated if 1. Signs of peritoneal irritation 2. unexplained shock 3. Evisceration of viscous 4. + ve DPL 5. Deterioration during observation 6. GSW 7. Stab wound with penetration of peritoneum Refrence — Baily and love short practice in surgery 59 1/00 Questions?