f. al-mashat dep of surgery kauh bowel injury. types : 1. blunt 2. penetrating: stab, gunshot 3....
TRANSCRIPT
F. Al-Mashat
Dep of Surgery
Kauh
BOWEL INJURY
TYPES :
1. Blunt
2. Penetrating: Stab, Gunshot
3. Operative
Mechanism:
1. Crushing: Compression 2. Shearing: Sudden Deceleration 3. Bursting: Abdominal Pressure
Causes:
1. Motor – Vehicle: 75%
2. High – Speed Vehicular
3. Fall from Heights
4. Seat Belt
Unrecognized : frequent cause of preventable death
Symptoms and Signs:
Unreliable
Often Masked:1. Head Injury 2. Major Fractures3. Alcohol
Signs:
1. Echymosis & Abrasions 2. Tender ribs
3. Peritonitis
a. Tenderness and Guarding : 75%
b. Rebound and Rigidity: 28%
4. Pelvic Fracture
5. DRE
6. Urethral blood
7. Tests, Perineum , Vagina
Investigations:1. CBC
2. U&E’s
3. LFT’s
4. Amylase
5. Clotting Profile
6. ABG
7. Urinalysis
8. CXR : A-P
9. KUB
10. DPL : 95 % Accurate
11. Contrast
12. CT
13. U/S
14. IVU /Contrast CT
15. Double – Contrast CT
16. Aortography : Embolization
The most frequently involved in penetrating (90%)
The 3rd in blunt
Penetrating: Gunshot: > 80%
Stab: 30%
Occurs in 5-15% of blunt
Small Bowel Injuries
Penetrating:
1. History 2. Examination
Not Sufficient
Blunt :“High Index of Suspicion”
Physical signs: Non Specific 1. associated injury2. Alcohol 3. Neutral PH & bacteria – minimal
inflammation
Delay
Laparotomy: 1. Four: Quadrant Survey
2. Control Enteric Contamination
3. Exploration ??
1. Haematoma & Laceration : Lembent, Transverse
2. Mural haematoma <1cm: Inversion
3. Small perforation : Close transverse
4. Adjacent perforations:divide, close transverse
5. Resection: A. Enterroraphy ½ diameter
B. Multiple injuries
C. Devascularized
Single, Double, Stapler
High Bacteria in terminal S. Bowel: repair in a distal to proximal fashion
Mesentry
Haematoma & Lacerations: >2cm, expanding, uncontained, near root mesentomy
Lesser Sac
Proximal Control Root Mesentry
Mattox
Evacuation
Ligation/SMA repair – saphenous vein/ graft
Second look 24H
Injury distal SMA
Bowel Resection +
Enteroenterostomy
Colon Injuries
• Majority: Penetrating
• Mortality: < 5%
Risk Factors :
• Shock: Sustained hypotensionmortality significantly
• Duration from injury to surgery morbidity not up to 12 H
• Faecal Contamination Quantity ? Major: > one Quadrant Class II & III: Major -- Sepsis
• Associated injuries:Class I, II, & III: > 2 organs -- Sepsis PATI > 25, FSS > 25 , Flint >11Class I: Greater # of associated organ
injury
Mortality & Sepsis
But : NO Contraindication to 1º repair of non destructive
• Anatomic Location: – Class I , II , & III: NO Significant
difference in complications between right & Left for 1º repair
• Blood Transfusion: 4 units critical > 4 → ↑ morbidity
Flint Severity Score:
• Isolated colon injury, minimal contamination, no shock, minimal delay.
• Perforation, lacerations, moderate contamination
• Severe tissue loss, devascularization, heavy contamination
Methods of Repair:
Primary Repair: The Standard Safe Right & Left (I, II, III)
Prospective Colostomy : Safe, conservative, acceptable
Closure: 10% Morbidity W. Infection I. Obstruction Fistula Incisional Hernia
Exteriorization:
a. Healing: 5 – 10 days
b. Colostomy
Abandoned: Failure & Complications
1. Drains : NO W. Infection Sepsis
2. Peritoneal Irrigation3. Wound:
Definitiona: Open: Significant
Contamination b: Delayed primary closure: 7 days
1. Class I & II: Single Pre - OP
aerobic & Anaerobic
2.Class I & II: 24 H hollow viscus
3. Shock : dose 2 – 3 folds
Prophylactic Antibiotics
Type: Single = Combination Aminoglycocide + Clindamycin
orAminoglycocide + metroindazole
Duration:Class I & II: 24 H
Optimal Dose: Fluid Shift High Dose Aminoglycocide: 3mg/Kg
Loading
Recommendations:
1. Class I & II: Non Destructive: 1º repair (Peritonitis º)
2. Destructive: 1º repair if:1 – Haemodynamic stable 2 – Shock °3 – Significant underlying disease º4 – Minimal associated injuries 5 - Peritonitis º
3. Complex: Shock + substantial contamination or trauma to other organs
Resection + proximal diversion
Colostomy/ Ileostomy
Mucous Fistula
Hartmann’s
Pregnancy
1. Blood Volume 2. Lax Abdominal Muscles
3. Enlarged Uterus
4. Pulse, BP, Haematocril, WBC, HCO3
5. Compressed Uterus: peripheral venous Pressure
6. GIT motility
Diagnostic Procedures: Same
1. Limit Radiation/ Shielding
2. Avoid Anaesthesia
3. DPL: Open
4. IVU: Single exposure
5. DIC
6. Early Mobilization of fracture
Special
1. Fetal Heart: Doppler (12w)2. U/S3. Placental Separation: Fetal cells in maternal blood
Treatment: Vigilant
Mother must be saved first
Options: as non pregnant 1. Uterine Injuries
2. Termination
In Majority: non injured uterus – V. Delivery at term
Injured uterus – repair
Indicators for C –Section :
1. Uterine rupture
2. Worseness fetal distress
3. Exposure of rectum, great vessels
4. Maternal Thoracolumbar spine fracture
5. DIC
6. MOF
Maternal death
Immediate Delivery
Poor infant survival if maternal death >15 minutes
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