dr. (brig) p. krishna murthy - medical sciences · introduction trauma is the most common cause of...
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ABDOMINAL TRAUMADr. (Brig) P. Krishna murthy
INTRODUCTION Trauma is the most common cause of death below 45
yrs ageIt is 3rd most common cause of death regardless of
ageDeath rate underestimates the magnitude of social tollIncidence of abdominal trauma- 13% of total trauma
cases40% trauma deaths are due to torso traumaIdentification of serious intra-abdominal injuries is
often challenging Many abdominal injuries may not manifest during the
initial assessment and treatment period
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TRIMODAL DEATH OF TRAUMA
CAUSES OF ABDOMINAL TRAUMA
1. Road traffic accidents- leading cause2. Falls3. Crush injuries4. Stab injuries5. Gun shot wounds6. Blast injuries
MECHANISM OF ABDOMINAL TRAUMABlunt trauma – energy is transferred over wide
areaPenetrating trauma – damage is localised to the
path of knife or bullet
INITIAL MANAGEMENT OF ABDOMINAL TRAUMA( ATLS Protocol) Approach to trauma patient is different from
other patientsC of ABC Determine if patient is in shockWarning signs- Deteriorating consciousness Pallor & cool extremities Tachycardia
INITIAL MANAGEMENT (CONTD.)
-Resuscitate if shock is present 2 large bore peripheral Iv cannulas 1-2 litres of crystalloid-Rapid assessment of source of blood loss “ one on floor and four more”-Investigations- chest x-ray AP view, x-ray pelvis AP view, FAST-Reassess for response to resuscitation i.e, Responders and non responders
FAST focusses only on 4 areas
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EVALUATION OF BLUNT TRAUMAMode of injuryClinical examination- 1/3 patients may not have abd
findingsRepeated examinations may be necessaryInvestigations- X-ray abdomen, chest and pelvis USG abdomen CT scan abdomen Peritoneal tap( 4 quadrant tap) DPL Angiography
CT ScanDone in Hemodynamically stable patientIv contrast / oral contrast is used
Advantages Retroperitoneal assessment can be madeNonoperative management of solid organ injuryHigh specificity
Disadvantages cost, radiationHollow viscus injuries, diaphragm injury are not seen
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DPLStandard criteria10cc gross bloodRBC>100,000/mm2 (5% miss)WBC>500/mm2
Amylase>175 IU/dLBile, bacteria, or food
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EVALUATION OF BLUNT TRAUMA
EVALUATION OF PENETRATING ABDOMINAL TRAUMA
GSWHaemodynamically unstable- Entry & exit wounds anterior expl laparotomy to mid axillary lines-
Entry & exit wounds posterior to mid axillary line- CT scan, laparoscopyTangential wounds-
EVALUATION OF PENETRATING ABDOMINAL TRAUMA (contd…)
LIVER TRAUMA
grade I HAEMATOMA: sub capsular, <10% surface area LACERATION: capsular tear, <1 cm depth
grade II HAEMATOMA: sub capsular, 10‐50% surface area HAEMATOMA: intraparenchymal <10 cm diameter LACERATION: capsular tear, 1‐3cm depth, <10 cm length
grade III HAEMATOMA: sub capsular, >50% surface area, or ruptured with active bleedingHAEMATOMA: intraparenchymal >10 cm diameter LACERATION: capsular tear, >3 cm depth
grade IV HAEMATOMA: intraparenchymal rupture with active bleedingLACERATION: parenchymal disruption involving 25‐75% hepatic lobe or involves 1‐3 Couinaud segments (within one lobe)
grade V LACERATION: parenchymal disruption involving >75% hepatic lobe or involves >3 Couinaud segments (within one lobe)VASCULAR: juxtahepatic venous injuries (IVC, major hepatic vein)
grade VI vascular: hepatic avulsion
MANAGEMENT 80% of patients with hepatic injuries can be managed
conservatively ( NOMLI )irrespective of grade of injury.
Indications for surgery (1) haemodynamically unstable patient
(2) multiple transfusions required to maintain haemodynamic stability
(3) signs of peritonism, or development of peritonism on serial abdominal examinations
(4) active arterial blush on CT for which interventional techniques ( angiographic embolisation) have failed
OPERATIVE MANAGEMENTOperative management can be summarised in 4 P’s
• PUSH ( Manual compression )PRINGLEPLUGPACK
The liver is packed with laparotomy pads to provide compressionagainst the abdominal wall, diaphragm, and retroperitoneum
Omental pedicle packing
Pringle maneuver:
Gallbladder injuries - cholecystectomy.
Bile duct injuries within the liver parenchyma may generally be managed nonoperatively
Duct transection with tissue loss or extensive injury should be treated with Roux-en-Y choledocho- or hepaticojejunostomy.
SPLENIC INJURY
GRADING OF SPLENIC INJURY
Management
Recent trend is Non‐operative management of splenic injury (NOMSI)
‐ hemodynamically stable patients with grade I, II, or III splenic injuries.
Angiography with embolization is a useful adjunct to NOMSI. Indications to Angiographic embolisation include CT evidence of ongoing bleeding with contrast extravasation outside or within the spleen
Indications for surgical intervention:o Hemodynamic instabilityo Grade IV, V splenic injuryo Evidence of continued splenic hemorrhageo Replacement of more than 50 % of the patient’s blood volume or need for more than 4 units of blood transfusions
o Associated intra‐abdominal injury requiring surgery
PANCREATIC TRAUMA
PANCREATIC INJURIES 1. BODY AND TAIL a. duct intact‐ nonoperative closed drainage b. duct involved‐ distal pancreatectomy/ pancreatico‐jejunostomy
+ closure of proximal cut end
2. HEAD a. No duct injury‐ closed drainageb. Duct injury‐ CBD injury Roux‐en‐y choledochojejunostomy + closure of
distal end ‐PANCREATIC DUCT injury central pancreatectomy+ Roux‐en‐
y pancreaticojejunostomyc. Destructive injuries‐ whipple’s ( pancreatico‐ duodenectomy)
Injury of body of pancreas with duct involvement‐ Roux‐en‐Y pancreaticojejunostomy
INJURIES TO STOMACHPrimary repair is done due to good vascularity
INJURY TO DUODENUM 1.Small perforations/lacerations‐ primary repair
2. Extensive injuries‐ 1st part‐‐‐Mobilise and end to end anastomosis2nd part‐‐‐patch with vascularised jejunal graft3rd part ( proximal to SMA )‐‐‐closure of distal stump+Roux‐en‐y duodenojejunostomy
3rd part (distal to SMA ), 4th part‐‐‐‐duodenojejunostomy left of SMA
INJURIES TO SMALL BOWEL Primary repair / resection anastomosis
INJURY TO COLON
No contamination‐‐‐ primary repairContamination present‐‐‐ colostomy
RENAL INJURY
Treatment of renal injuryMost blunt renal injuries, including all grade 1 and
2 and most grade 3 and 4 injuries, can be safely treated conservatively.
Surgical Intervention is required for patients with the following:Persistent bleeding (ie, enough to necessitate
treatment for hypovolemia)Expanding perinephric hematomaRenal pedicle avulsion or other significant
renovascular injuries
INJURY TO URINARY BLADDERIntra peritoneal rupture‐‐‐ primary repairExtra peritoneal rupture‐‐‐ conservative management
RETROPERITONEAL TRAUMA
Zones of retroperitoneal injury. zone I, central (injuries to aorta and caval vein and their main branches as well as duodenum and pancreas) zone II lateral (injuries to kidney and bowel vssels) zone III pelvic (injuries to pelvis and iliac arteries and veins)
Zone I :- midline retroperitoneal hematomas “all” need surgical exploration, as they commonly result in injury to vital structures. Zone II :- surgery done if there is expanding
hematomaZone III :- conservative management
DAMAGE CONTROL SURGERYMinimising surgery until the physiological derangements can be corrected.Components ‐Stopping active bleeding ‐controlling contamination Decision for damage control surgery to be taken at the earliest in ED or at the beginning of surgery.
DAMAGE CONTROL SURGERY contd..Stages of damage control surgery 1. Patient selection 2. Control of hemorrhage and contamination 3. Resuscitation continued in ICU 4. Definitive surgery 5. Abdominal closure
DAMAGE CONTROL SURGERY contd..INDICATIONS:‐ ANATOMICAL‐ ‐ Inability to achieve hemostasis ‐ Complex abdominal injuries ( ex: liver and pancreas ) ‐ Combined major vascular , solid and hollow organ injuries ( ex: IVC, AORTA etc )
‐ Inaccessible major venous injury ( ex: retrohepatic vena cava )
DAMAGE CONTROL SURGERY contd..PHYSIOLOGICAL ‐ Acidosis (pH<7.2) ‐ Coagulopathy ( PT > 19 sec, PTT> 60 sec ) ‐ Massive blood transfusion ( > 10 units ) ‐ Hypotension ( < 90 mm Hg for more than 1hr )
Vac‐pack dressing
(a) covering the bowel with a fenestrated plastic drape, (b) placement of closed‐suction drains and a towel, ( c ) adhesive occlusive dressing
“Vac‐Pack” dressing :‐(1)A fenestrated plastic sheet is draped over the bowel and extended to the paracolic gutters to keep the bowel from adhering to wound edges.
(2) A towel is placed over the sheet to prevent suction drains from adhering to bowel through the slits in the plastic sheet.
(3)Drains are placed on top of the towel. (4) Finally, an adhesive drape is placed over the entire wound
CONCLUSIONAbdominal trauma constitutes an important group of injuries requiring proper assessment and prompt management to decrease the mortality.Operative decisions for blunt trauma abdomen are more challenging than penetrating trauma.Majority of solid organ injuries can be managed conservatively.Surgical team should make a decision for damage control surgery as early as possible.
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