Moderators: Dr. S.A. Halkai Dr. R. Anil Dr. S.S. Karbhari Dr. Vikram Dr.

Nitin Kalaskar

Presented by.. Dr. Veerabhadra R.

28th March 2011

 About

40% of all trauma deaths occur because of major hemorrhage. of Major hemorrhage are

Sites

External Chest Abdomen Pelvis Muscle compartment

As

abdomen is a Magic box, one should never neglect it post-trauma.

 Anterior

abdomen:

5th ICS superiorly. Inguinal ligaments and Pubic symphysis inferiorly. Anterior axillary lines laterally.

Flank:

Between anterior and posterior axillary lines from 5th intercostals space to iliac crest.

Back:

From inferior angle of scapulae to iliac crest, between posterior axillary lines.

 Intra

thoracic abdomen:

Portion of upper abdomen beneath rib cage, inaccessible for palpation. Diaphragm, Liver, Gall bladder, Spleen & Stomach.

True abdomen:

Small & Large intestines. Uterus (gravid) & Bladder (if distended). Injuries present with significant signs and symptoms.

Pelvic abdomen: Defined by the true Pelvis. Urinary bladder, Urethra, Rectum, Small intestine, Pelvic vascular plexus, Iliac arteries, Iliac Veins. Ovaries, Fallopian tubes and Uterus in females. Injuries to these structures are difficult to diagnose as these are extraperitoneal. Retroperitoneum: Pancreas, Kidneys, Ureters, Aorta and Inferior Venacava. Injuries are difficult to diagnose, evaluated by CT Scan, Angiography and IVP.

 Blunt

trauma:

Forces:
Crushing Decceleration/Shearing External Compression

Sources:

Motor Vehicle Accidents y Seat belt injury y Steering wheel injury Falls Assaults Blast

 Penetrating

trauma:

Low velocity

Knife, Ice pick. Injury limited to area near penetration

Medium velocity

Gunshot/handgun, Shotgun. Extensive external soft tissue injury.

High velocity

High power hunting rifle, Military weapon.

 Blunt

trauma:

Spleen Liver Kidney

Penetrating

trauma:

Small Intestine Liver Colon

Lap seat belt

Mesenteric tear or avulsion. Rupture of small bowel or colon. Iliac artery or abdominal aorta thrombosis. Chance fracture of lumbar vertebrae (hyperflexion).

Shoulder Harness

Rupture of upper abdominal viscera. Intimal tear or thrombosis in innominate, carotid, subclavian or vertebral arteries. Fracture or dislocation of C-spine. Rib fractures. Pulmonary contusion.

Air Bag
Corneal abrasions, keratitis. Abrasions of face, neck, chest. Cardiac rupture. C or T-spine fracture.

 AMPLE

history:

Allergies Medications Past Medical/Surgical History Last meal Events related to the injury

Clinical

Examination:

Its not necessary to determine in the casualty which intra-abdominal organ is injured, only whether exploratory laparotomy is necessary or not. Drugs, Alcohol, Head injury and Spinal cord injury complicate clinical evaluation.

 Head-to-Toe

Examination with special attention to Axilla, Back and Perineum. of shock:

Signs

Tachycardia, tachypnoea, hypotension Cold clammy hands, acidotic breathing.

Local

Examination of Abdomen:

Inspection:
External signs of injury Respiratory patterns Abdominal distension Abdominal discoloration y Cullens sign, Grey-Turners sign Kehrs sign

Palpation:

Abnormal mass, tenderness and deformity. Fullness and doughy. Instability of thoracic cage. Pelvic instability. Abdominal Girth. Guarding and Rigidity. Tympanic Dull Percussion tenderness Balances sign Bruit Bowel sound

Percussion:

Auscultation:

Genitals & Perineum Rectal Examination Vaginal Examination

Rapid and accurate 97-98% sensitive Pre-requisites:

NG tube Foleys catheter

Indications:

Unexplained shock spinal cord injury suspected abdominal injury in comatose, intoxicated or multiple injury patients.

Contra-indications:

Stab/Gun shot wounds Pregnancy

Non-invasive, easily performed, Rapid, portable. Can be done in unstable patients Investigation of choice for Hemoperitoneum Focusses on..

Pericardium Peri-splenic region Hepatorenal pouch Pelvis 250 cc total 100 cc in Morisons pouch

Can detect..

75-90% sensitive. 95-100% specific. Unreliable in penetrating trauma and cant detect hollow viscus injury.

HEPATIC

SPLENIC

PERICARDIAC

PELVIC

 Investigation

of choice..

Retroperitoneal injuries Non-operative management of Solid visceral injury

Gold-standard

investigation for intraparenchymal injuries. Done after IV or Oral contrast. 92-98% sensitive and 99% specific. Pitfalls:

Cant be done in unstable patients. Costly, time consuming. Limited sensitivity for mesenteric/hollow viscus injuries.

 Valuable

in penetrating trauma in stable patient, to detect or exclude peritoneal penetration and/or Diaphragmatic injury. It reduces non-therapeutic laparotomies.

Penetrating:

Path of a penetrating object Locates foreign body Blunt: Air under diaphragm (hollow viscus perforation)

Can

show which vessel is bleeding

 Evaluation

of penetrating trauma abdomen

Hemodyanamics

Stable

Unstable

Gun Shot Wounds Anterior abdomen

Stab wounds Back flank Anterior abdomen

UQ

CT Scan

DPL/CT

EXPLO ATO Y LAPA OTOMY

 Primary principles:

Airway Breathing Circulation Disability Environment & Exposure

Treat

shock

MAST/PASG application w/o inflation may be helpful in pelvic fractures IVF titrate as per BP

Indirect

ice may be helpful in genitalia injury

Collect and package amputated genitalia

 Abdominal

Evisceration

Do not replace organs into abdomen Cover exposed bowel with saline moistened multi trauma dressing Cover first dressing with second dry dressing

Nill

By Mouth Caution with

Sedatives Narcotic Analgesics

Patients

with Abdominal trauma are classified as..

Hemodynamically NORMAL- can be properly investigated and treatment can be planned. Hemodynamically STABLE- Investigations limited to establish whether patient requires operative/nonoperative therapy

Hemodynamically UNSTABLE: Immediate surgical correction is required.

Non-Operative

treatment:

Non-operative treatment for blunt injuries of Liver, Spleen and Kidneys in now the rule rather than the exception provided the patient is hemodynamically stable. 90% of children and 50% adults can be treated in this manner. Accurate CT imaging is a pre-requisite. The patient should be monitored in ICU for 1st 24hrs. Complications:

Continuing hemorrhage, delayed hemorrhage Necrosis of liver, spleen or kidney from embolization Abscess, biloma, Urinoma

Bleeding is treated by embolization; infection by percutaneous drainage; Biloma usually are resorbed.

LAPAROTOMY:

Indications:

Signs of peritonitis Evisceration of viscus Uncontrolled shock or hemorrhage Clinical deterioration during observation Hemoperitoneum findings after FAST or DPL examinations

Incision: Median; transverse (in children <6yrs)

Intervention radiology:
Diagnostic as well as therapeutic toool for vascular injury. Ongoing bleeding in liver, spleen kidney and pelvic vessels can be treated by Angio-embolisation. In penetrating trauma, these can detect Pseudo-aneurysms and A-V fistulae, which can be stented.

Following a major trauma, the unstable patient dies because of THE DEADLY TRIAD. i.e.,
Hypothermia Acidosis Coagulopathy

The best way in improving the outcome is by minimising surgery until the patients physiological derangement is corrected. This is technically demanding & challenging for the trauma surgeon. Theres no margin for error and no place for careless surgery.

 Goals:

Control of Hemorrhage

Packing/ligation/clamping Balloon tamponade- Sengstaken tube/Foleys catheter Angio-embolization for expanding pelvic hematoma or liver injury Ligation/stapling/simple closure

Control of Contamination

Stages:

Patient selection Control of hemorrhage & contamination Temporary abdominal closure

Towel clip/silobag/vacuum pack.

Resuscitation in ICU Definitive surgery Abdomen closure

 Salient

features:

Warm IVF Damage control resuscitation Long incision 1st manoeuvre is packing, upto 30 mops can be used. Liver- Packing, Pringle manoeuvre followed by Angioembolization. Spleen- Go for splenectomy as spleen conserving surgery is time consuming. Aorta- shunting IVC- direct pressure above and below by sponge sticks, followed by direct suturing or packing if retroperitoneal. GIT- Suture small holes; No anastomosis or Stomas; Resect non-viable bowel and close the ends.

 Definitive

surgery:

In 24-48 hrs Too early unstable, oedema Too late complications like ARDS, SIRS.

 Abdominal

compression causes raised intra-abdominal pressure leading to the rupture

abdominal contents rupture through diaphragm into chest bowel obstruction and strangulation restriction of lung expansion mediastinal shift

90%

occur on left as right side is protected by liver. Features:

Chest: breath sounds, dull note. Abd: scaphoid, Absent Bowel Sounds. CXR/NG tube Video Assisted Thoraco/Laparoscopy

Treated

by open repair via abdomen.

(No.1 prolene with simple running sutures)

 Suspect

liver injury with external injury to right side of the chest below nipple, right upper quadrant of abdomen and epigastrium. scan and volume of blood in abdomen helps in knowing severity of injury. management is the rule as 86% of liver injuries stop bleeding by the time of surgical exploration. reserved in patients with other organ injury, increasing instability or failure of nonoperative management.

CT

Non-operative

Surgery is

Ps of Management:
Push: Direct pressure Pringle: direct pressure on portal triad in lesser sac Plug: Silicone tube or Sengstaken-Blakemore tube Pack

Hepatic

Artery can be tied but Portal vein must be repaired.

Complications: Recurrent bleeding(24-48 hrs) Biloma Hematobilia Billiary Fistula

Perihepatic abscess Intrahepatic Haematoma Pulmonary Complications Coagulopathy

 Secondary

to penetrating trauma. Occurs in association. Hepatic duct:

One: ligate it Both: external drainage, followed by repair.

Cholecystectomy:

Gall bladder injury or postligation of right hepatic A. CBD is injured along with portal vein injury. CBD injury is repaired over a T-tube or drained. Roux-n-Y choledochojejunostomy can also be done.

 Suspect

when left lower chest injuries, left Upper quadrant abdomen injuries. Non-operative management is the rule for isolated splenic injury. CT for staging Angioembolization. Operative:

Splenorrhaphy: Ideal Partial Splenectomy: Sup/Inf polar injuries Splenectomy:

Hilar pulverized splenic parenchyma >grade 2 injury with coagulopathy or multiple injuries

 Post-Operative

Complications:

Re-bleeding:

loosening of tie around splenic vessels. Improperly ligated or unrecognised short gastric artery. Recurrent bleeding from the repair.

Sepsis:

An initial rise in platelet & WBC is normal. If WBC count >15,000 and (Platelet/WBC) <20 after POD suspect sepsis. Subphrenic abscess is the most common cause, treated by percutaneous drainage.

Overwhelming Post-Splenectomy Sepsis (OPSS):

Agents: y S. Pneumoniae, H. Influenze and N. Meningitidis. Vaccination optimally at 14 days.

Penetrating or blast injuries. An entry wound always has an exit wound or a residual weapon. Full stomach prior to incident risk of injury Spillage of contents into peritoneal cavity

Immediate pain, tenderness, guarding, and rigidity

Spillage of bacteria into peritoneal cavity

Takes 24-48 hrs to develop features of peritonitis

Minor wounds are sutured with a running single layer sutures.

 Destructive

injuries:

Stomach: Partial gastrectomy with or without a drainage procedure in case of stomach. Intestines: Segmental resection with end-to-end anastomosis.

Haematomas

in small bowel mesenteric border to be explored to rule out perforation. injuries are treated with Resection and Anastomosis. complications:

Mesenteric

Post-Op

Anastomotic failure. Abscess.

 Frequently

associated with adjoining pancreatic

injury.
Hidden,

only sign may be gas in periduodenal tissue seen on CT. injuries:

Minor

Conservative Rx with NG tube and parenteral nutrition. A running single layer suturing.

 Major

injuries:

1st part: Repair and end-to-end anastomosis because

of mobility and rich blood supply of distal stomach. 2nd part:

Not more than a cm of duodenum can be mobilized, so treated by debridement and a patch of vascular jejunal graft. Roux-en-Y duodenojejunostomy with closure of distal portion of duodenum. Resected and a duodenojejunostomy on the left of superior mesenteric vessel.

Distal to Papilla of vater and Proximal to SMA:

Distal to SMA:

 Only

Parenchymal:

Conservative or with closed suction drainage if underwent laparotomy for other indication.

Associated

with ductal disruption:

Diagnosed by Open exploration, Operative pancreatography or ERCP. Stable: Distal pancreatectomy with Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy. Unstable: Distal pancreatectomy with splenectomy.

The pancreatic duct in the proximal edge of the transected pancreas should be ligated with application of fibrin glue to the stump. Pancreatic body: Central pancreatectomy with Roux-en-Y pancreaticojejunostomy Pancreatic head: Whipples procedure with Roux-en-Y choledochojejunostomy.

 Develop

features of Peritonitis in 6 hrs. Primary repair with a running single layer suturing. End colostomy followed by secondary repair.

 Usually

associated with bladder or proximal urethral injury. Intraperitoneal:

Treated as Colonic injury.

Full

thickness/extraperitoneal:

End colostomy with closure of distal rectum.

 Penetrating:

Explore all penetrating wounds to the kidney. As per liver/spleen injury. Collecting system should be closed separately. Renal capsule is preserved to close over the repair of the collecting system. Renovascular injuries are repaired by graft. Partial or complete Nephrectomy for destructive parenchymal or irrepairable vascular injuries.

 Blunt:

>90% blunt Renal injuries are treated conservatively. Bladder irrigation to dispel blood clots. Urinomas are percutaneously drained. Operative repair is required for..

Destructive parenchymal injuries leading to hypotension. Renovascular injuries.

 Proximal:

End-to-end anastomosis, urinary diversion, ileal interposition. Distal:

 Intra-peritoneal:

A running single layer suturing with absorbable 3-0 monofilament suture. Bladder decompression by Foleys catheter for 2 wks.

Extra-peritoneal:

Defect

bridged by Foleys catheter with or without direct suture repair.

 Central:

Always explore with proximal and distal vascular control Lateral: Usually renal in origin, non-operative management, sometimes angioembolisation. Pelvic: Never explore. Packing and Angioembolisation