the problem · no peritonitis non-operative management penetrating abdominal trauma...
TRANSCRIPT
1
Acute management of penetrating trauma
Karim Brohi BSc FRCS FRCA
The Royal London Hospital
The problem
2
The problem
The problem
3
Principles
Determinants of outcome
• Time to haemorrhage control• Physiological derangement• Stab or gunshot injuries• Number of organs injured
Change your mindset
This is no longer a standard resuscitation
Damage Control
Stop haemorrhagePrevent sepsis
Get out
4
Change your mindset
Treatment of haemorrhagic shock is arrest of haemorrhage,
not haemodilution
Change your mindset
Physiological exhaustion
Hypothermia
Coagulopathy Acidosis
5
Change your mindset
Traditional
Damage Control
Penetrating neck trauma
6
Penetrating neck trauma
At risk structures:
AirwayVascularOesophagusNeural
Penetrating neck trauma
Non-operative management
No injury compromising airway
No shockNo expanding haematomaNo progressing strokeNo neurological deficit
No dysphagia/odynophagiaNo subcutaneous emphysema
7
Penetrating neck trauma
Penetrating neck trauma - vascular
8
Penetrating neck trauma - vascular
Penetrating neck trauma - vascular
9
Penetrating neck trauma - vascular
Penetrating head trauma
10
Penetrating torso trauma
Penetrating torso trauma
Haemodynamically unstableLaparotomy and/or thoracotomy
11
Penetrating torso trauma
Haemodynamically unstableLaparotomy and/or thoracotomy
Penetrating torso trauma
Chest X-rayFAST
12
Penetrating abdominal trauma
Haemodynamically stable patientReliable clinical exam
No peritonitisNon-operative management
Penetrating abdominal trauma
Haemodynamically stable patientUnreliable clinical exam
CT scan
(Diagnostic Peritoneal Lavage)(Laparoscopy)
13
Penetrating abdominal trauma
Peritoneal violation is NOT the issue
Local wound exploration isunhelpful
Penetrating abdominal trauma
14
Penetrating abdominal trauma
15
Penetrating torso trauma - diaphragm
Stab wounds usually smallDifficult to see on X-ray
16
Penetrating torso trauma - diaphragm
Haemothorax and positive FAST
Ultrasound?MRI? CT?
LaparoscopyThoracoscopy
17
Peripheral vascular injury
Peripheral vascular injury
18
Peripheral vascular injury
AngiographyMay be on-table
High velocity injuriesBlunt trauma
Multiple level injuriesPeripheral vascular disease
Not for proximity
Summary
Treatment of haemorrhagic shock is arrest of haemorrhage.