Blunt trauma abdomen ankit
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This document provides information on the management of blunt trauma to the abdomen. It begins with an overview of the regional anatomy of the abdomen and mechanisms of injury. It then discusses the initial management, physical examination and investigations for patients with blunt abdominal trauma. Specific imaging studies like abdominal x-ray, FAST, DPL, CT scan and their indications are explained. The document outlines the indications for laparotomy and approaches to managing specific organ injuries like liver and spleen trauma encountered during surgery. Post-operative management and complications are also summarized.
![BLUNT TRAUMA
ABDOMEN
DR ANKIT SHARMA
RESIDENT [SURGERY]
ARMED FORCES MEDICAL COLLEGE
PUNE](https://image.slidesharecdn.com/blunttraumaabdomen-ankit-170515192541/85/Blunt-trauma-abdomen-ankit-1-320.jpg)
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Blunt trauma abdomen ankit
- 1. BLUNT TRAUMA ABDOMEN DR ANKIT SHARMA RESIDENT [SURGERY] ARMED FORCES MEDICAL COLLEGE PUNE
- 2. Scheme of presentation Regional anatomy of abdomen Mechanism of injury Initial management Examination Investigations Laparotomy Indications Approach Management of specific injuries Abdominal Compartment Syndrome 2
- 3. Regions of abdomen Anterior Abdomen Superiorly – b/w costal margins Inferiorly – Inguinal ligament & pubic symphysis Laterally – Ant axillary lines Majority hollow viscera may be involved 3
- 4. Regions of abdomen Thoraco Abdomen Inferior to Anteriorly: Trans-nipple line Posteriorly: Infra-scapular line Includes Diaphragm, Liver, Spleen & Stomach Full expiration diaphragm rises to 4th ICS Abdo viscera may be injured by penetrating wounds/ # lower ribs 4
- 5. Regions of abdomen Flank Anteriorly – Ant axillary line Posteriorly – Post axillary line Superiorly – 6th ICS Inferiorly – Iliac crest Thick musculature – partial barrier to penetrating wounds 5
- 6. Regions of abdomen Back Posterior to posterior axillary line From – tip of scapulae To – Iliac crest 6
- 7. Regions of abdomen 7
- 8. Regions of abdomen Pelvis Lower part of retroperitoneal and intraperitoneal spaces Rectum, bladder, iliac vessels, internal reproductive organs (females) 8
- 9. Stats MVAs responsible for 75% of all blunt abdominal trauma Multi-organ & multi-system injury Solid organ injury >> Hollow viscus injury Spleen (40-55%) > Liver (35-45%) > Small bowel (5-10%) Retroperitoneal hematoma (15% laparotomies) 9
- 10. Mechanism of injury CRUSHING Direct application of a blunt force to the abdomen SHEARING Sudden decelerations apply a shearing force across organs with fixed attachments BURSTING Raised intraluminal pressure by abdominal compression in hollow organs can lead to rupture PENETRATION Disruption of bony areas by blunt trauma may generate bony spicules that can cause secondary penetrating injury 10
- 11. Injuries from restraint devices 11
- 12. Standard initial protocol Spinal stabilization Maintenance of ABC IV access (double) and IV fluids Draw and send blood for investigations, blood grouping NG tube insertion Urinary catheterization 12
- 13. History Mode of injury (MVA/ direct blow/ fall from height) Type of veh & speed Type of collision (frontal/ lateral/ side/ rear/ rollover) Response to pre-hospital treatment (by trauma care personnel) Explosion – visceral overpressure injuries (more in closed spaces and less distance of patient from explosion) 13
- 14. Physical Examination: Inspection Fully unclothe the patient Whole body thorough inspection abrasions, contusions from restraint devices, lacerations, penetrating wounds, impaled foreign bodies, evisceration of omentum or small bowel, and the pregnant state Flank, scrotum & perianal area – blood @ meatus, swelling, bruising, laceration of perineum, vagina, rectum or buttocks (s/o open pelvic #) 14
- 15. The classical ‘seatbelt’ sign. The bruising on the left breast is from the shoulder belt and the low bruising to the abdominal wall is from the lap belt. 15
- 16. Physical Examination: Palpation & Percussion Tenderness (Superficial/ deep) Rebound tenderness Guarding (Voluntary/ involuntary), rigidity Dullness/ shifting dullness – intraabdominal collection 16
- 17. Physical Examination: Auscultation Difficult in a noisy room Bowel Sounds +/- Reliable only when initially present and change later Absence of bowel sounds – non-specific 17
- 18. Pelvic Stability Testing Pelvic hemorrhage occurs rapidly - Unexplained hypotension Compression-distraction maneuver Perform only once; may result in further hemorrhage Ruptured urethra (high riding prostate, scrotal hematoma, blood @ meatus) Limb lengthening discrepancy Rotational leg deformity without e/o fracture 18
- 19. Others Vaginal examination In presence of complex perineal lacerations/ pelvic # or trans-pelvic GSW Vaginal laceration may be seen due to pelvic # or penetrating wounds Gluteal examination From iliac crest to gluteal folds Penetrating injuries – rectal injuries below peritoneal reflection GSWs & stab wounds – associated with intra-abdominal injuries 19
- 20. Others NG tube Relieve acute gastric dilatation Decompress stomach before a DPL Remove gastric contents Blood in NG Esophageal/ upper GIT injury (after excluding naso/ oro-pharyngeal sources) Urinary catheter (or SPC) Relieve retention Decompress bladder before DPL Monitor UO as indicator of tissue perfusion Gross hematuria trauma to genitourinary tract & non renal intraabdominal organs 20
- 21. INVESTIGATIONS – Aim To identify To decide When (those with injury) (which ones (how quickly need laparotomy) this must be undertaken) DIAGNOSTIC STRATEGY
- 22. DIAGNOSTIC STRATEGY cont.. Complete hemogram with hematocrit ABG, Electrocardiogram Renal function tests Urine analysis – +nce of hematuria – genitourinary injury -nce of hematuria – does not rule out it Serum amylase / lipase or liver enzymes - se -suspicion of intraabdominal injuries
- 23. Imaging studies Abdominal X-ray FAST DPL CT Scan Contrast studies 23
- 24. Abdominal X-ray Pneumoperitoneum – hollow viscus perforation Ground glass appearance – massive haemoperitoneum Dilated gut loops- retroperitoneal hematoma/ injury Retroperitoneal air outlining the right kidney – duodenal injury Double wall sign – air inside and outside the bowel Distortion or enlargement of outlines of viscera – hematoma in relation to respective organs 24
- 25. Abdominal X-ray Medial displacement of stomach – splenic hematoma Obliteration of Psoas shadow – retroperitoneal bleeding Pelvic bone fracture – bladder/urethral/rectal injury Fracture vertebra – ureter injury / retroperitoneal hematoma 25
- 26. Chest X-ray Pneumothorax/haemothorax Raised left/right hemidiaphragm – perisplenic/hepatic hematoma Lower ribs fracture – liver/spleen injury Abdominal contents in the chest – ruptured hemidiaphragm 26
- 27. Indications for investigating further Unexplained hemorrhagic shock Major chest or pelvic injuries Abdominal tenderness Diminished pain response due to Intoxication Depressed level of consciousness Distracting pain Paralysis Inability to perform serial examination 27
- 28. FAST Focused Assessment Sonography in Trauma Rapid, accurate, non invasive, inexpensive study Operator dependant Views Pericardial view (Subxiphoid/ parasternal view) RUQ view - diaphragm-liver interface and Morrison’s pouch (Sagittal view in MAL in 10th or 11th ICS) LUQ view - diaphragm-spleen interface and spleen-kidney interface (Sagittal view in MAL in 8h or 9th ICS) Suprapubic view (Transverse; before inserting foley’s) 28
- 29. FAST Low frequency (3.5 MHz) transducer; allows depth of penetration necessary to obtain appropriate images ± Second scan 30 min after initial scan - progression Negative FAST doesn’t rule out intra-abdominal injury Difficult in subcutaneous emphysema, obese and previously operated pts Absolute indication for a laparotomy = contraindication for FAST Pelvic # may decrease the accuracy 29
- 30. DPL Diagnostic Peritoneal Lavage Rapid, invasive, 98% sensitive for intraperitoneal bleed Indications Patients with spinal cord injury Those with multiple injuries and unexplained shock Obtunded patients with a possible abdominal injury Intoxicated patients in whom abdominal injury is suspected Patients with potential intraabdominal injury who will undergo prolonged anesthesia for another procedure 30
- 31. DPL Open, semi-open or closed method Gross blood aspirated – go for Laparotomy No gross blood – instill 1 lit of warm NS (child – 10ml/kg) – gently agitate the abdomen Adequate fluid return is > 20% of infused volume Negative lavage doesn’t exclude retroperitoneal injuries e.g. pancreatic or duodenal injuries 31
- 32. 32
- 33. DPL Absolute contraindication = obvious need for laparotomy Relative contraindications Pregnancy Morbid obesity H/o multiple abdominal surgeries Positive if 10 ml grossly bloody aspirate before infusing lavage fluid >100,000/μL RBCs; >500 /μL WBCs; Only 30mL blood reqd to produce microscopically positive DPL result ↑ amylase, bile, bacteria, vegetable matter or urine + 33
- 34. DPL Hemorrhage (false positive results) secondary to injection of local anesthetic Incision of the skin or subcutaneous tissues Peritonitis due to intestinal perforation from the catheter Laceration of urinary bladder (if bladder full) Injury to other abdominal and retroperitoneal structures requiring operative care Wound infection at the lavage site (late complication) 34
- 35. Abdominal CT Scan Hemodynamically stable patient Not in emergent need of laparotomy ± Contrast administration (non-ionic contrast) Organ injury & extent Retroperitoneal/ pelvic organ injuries Can miss some GI, diaphragmatic and pancreatic injuries Free fluid with no hepatic/ splenic injury suspect GI or mesenteric trauma 35
- 36. DPL Vs FAST Vs CT 36
- 37. Contrast studies Urethrography Cystography IVP GI Contrast studies 37
- 38. The big question: Which patients need Laparotomy ? 38
- 39. Small answer Blunt abdominal trauma with hypotension with a positive FAST or clinical evidence of intraperitoneal bleeding Blunt or penetrating abdominal trauma with a positive DPL Hypotension with a penetrating abdominal wound Gunshot wounds traversing the peritoneal cavity or visceral/vascular retroperitoneum 39
- 40. Small answer Bleeding from the stomach, rectum, or genitourinary tract from penetrating trauma Peritonitis Free air, retroperitoneal air, or rupture of the hemidiaphragm CECT findings of ruptured GIT, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma 40
- 41. LAPAROTOMY Generous midline incision Transverse incision in children < 6 yrs Scalpel better than cautery. Forget the bleeding from incision till definite source of bleed found Remove blood and blood clots with abdominal swabs Palpate spleen and liver first and pack if fractured Source localized direct digital occlusion (vascular injury) or pad packing (solid organ injury) Liver bleed – hepatic pedicle clamping with vascular clamp (Pringle maneuver) 41
- 42. Liver bleed control 42
- 43. LAPAROTOMY Splenic bleed – clamp splenic hilum (better than packing alone) Rotate spleen medially Incise lateral peritoneum & endoabdominal fascia Spleen and pancreas can be dissected from retroperitoneum as a composite , ant to Gerota’s fascia 43
- 46. Liver trauma 46
- 47. Liver trauma 47 Primary aim is to arrest bleeding Perihepatic packing is effective most of the times, if not then perform Pringle maneuver Difficult to perform perihepatic packing in Lt lobe Mobilize it and compress between surgeon’s hands Pringle maneuver Bleeding stopped => from AHA / PV Doesn’t stop => HVs and retrohepatic IVC is the source Packing Failed direct vascular repair ± hepatic vascular isolation Repair the Hepatic artery proper Cholecystectomy if Rt hepatic artery is ligated
- 48. Liver trauma 48 Minor lacerations Manual compression Topical hemostats (cautery, argon beam coagulator, gelfoam, fibrin glue, collagen) Shallow lacerations running suture Deep lacerations Interrupted Hz mattress parallel to edge of laceration Omentum to fill large defects (obliterates dead space; source of macrophages) Deep recalcitrant hemorrhage hepatic lobar arterial ligation
- 49. Liver trauma 49 Repeat laparotomy within 24 hrs for pack removal Ongoing hemorrhage – early exploration (<24h h) Complex injuries – angioembolization Complex injuries – typical ‘liver fever’ upto 5 days post injury Non-anatomical resection – stable without coagulopathy GB injury cholecystectomy EHBD Transaction Roux-en-Y choledochojejunostomy Till then intubate the duct for external drainage Complications – hemorrhage, hepatic necrosis, bilomas, arterial pseudoaneurysms and biliary fistulas
- 50. Liver trauma - NOM 50 Basis 50-80% of liver bleed stops spontaneously Better results of NOM in children Significant development of CT scan in liver imaging Initially introduced for minor injuries (1972) Presently being used for grades III – V also Selection criteria Hemodynamic stability after initial resuscitation No other visceral/ retroperitoneal injuries needing surg Multidisciplinary team – Experienced surgeon, Intensivist, CT scan, 24x7 OT facilities
- 51. Liver trauma - NOM 51 Failure rate significantly higher in Gd IV & V than Gd I- III Most common reason for intervention – co-existing abdo injury (e.g. bleed form spleen or kidney) Predictors of NOM failure Advanced age Anaemia & HTN Active extravasation on CT Massive blood transfusion CT follow up for Gd I & II not necessary Others need clinical and CT follow up
- 53. Splenic trauma 53 Management options Observation Angiographic Embolization (Gd I-III; age < 55y) Surgery (Splenectomy/ partial splenectomy/ splenorrhaphy) Depending upon Hemodynamic status of pt Grade of injury Presence of other injuries Medical co-morbidities Upto 20% patients require early splenectomy Delayed hemorrhage/ rupture can occur weeks after injury
- 54. Splenic trauma 54 Splenectomy (with auto-transplantation) Hilar injuries Pulverized splenic parenchyma GD III and above + coagulopathy/ multiple injuries Partial splenectomy – isolated polar injuries Splenorrhaphy – cautery, argon beam coagulator, gelfoam, fibrin glue, collagen, envelopment in absorbable mesh, pledgeted suture repair Bleeding edges – Hz mattress sutures + parenchymal compression
- 56. Splenic Bleeding Edges 56
- 57. Splenic trauma 57 Post splenectomy hemorrhage Loosening of tie around splenic vessels Improperly ligated/ missed short gastric artery Recurrent splenic bleed Post-op complications Subphrenic abscess (pigtail drainage) Pancreatic tail injury (Iatrogenic) Gastric perforation (during short gastric ligation) OPSI
- 58. Splenic trauma - NOM 58 Basis Salvaging functional splenic tissue – avoids surgical & anesthetic complications No risk of post-splenectomy abscess Indications Hemodynamically stable patients (Gd I - III) No other intra-abdominal injuries needing laparotomy Active contrast extravasation/ blush on CT > 70 % patients still undergo splenectomy after NOM Higher failure rates of NOM with increasing grades of severity
- 59. Splenic trauma – NOM 59 Absolute bed rest & NPO 6 hrly Hb check in first 24h Allowed orally if Hb stable & no surg intervention likely Follow-up CT: Falling Hb, abdo pain, fever, Lt shoulder pain Duration based on Gd of splenic injury Nature & severity of other injuries Clinical Status (Incl peritoneal signs – missed hollow viscus injury & Hb levels) Embolization – 73-97% success rate
- 60. Stomach & Small Intestine 60 Gastric Wounds – running single layer suture (full thickness bites)/ stapler Partial gastrectomy – for destructive injuries Small intestine injury < 1/3rd of bowel circumference transverse running 3-0 PDS Multiple injuries/ mesenteric injuries – segmental resection and anastomosis/ stoma Post-op ileus is obligatory No enteral feeds for atleast 48 hrs TEN to be started at 20mL/h once resuscitation is complete
- 61. Duodenum 61 Duodenal hematoma – NG aspiration & parenteral nutrition Small duodenal perforation/ laceration – primary single layer repair 1st part injuries – debridement & end-to end anastomosis with gastric antrum/ pylorus 2nd part injuries – patch with vascularized jejunal graft 3rd & 4th part injuries – resection and anastomosis on Lt side of Superior mesenteric vessels Pyloric exclusion – high risk, complex duodenal repairs
- 62. Pancreas 62 Management depends on location of injury to Parenchyma Intrapancreatic CBD MPD Contusion (ductal system intact)/ proximal pancreatic injuries (to Rt of SM vessels) Non operative/ closed suction drain Distal duct disruption (body & tail) – distal pancreatectomy with splenic preservation Injury to Head with duct injury – distal duct ligation with Roux-en-Y choledochojejunostomy
- 63. Colon & Rectum 63 3 methods for colonic injuries Primary repair End colostomy Primary repair with diverting colostomy Weigh the risk of primary repair Vs colostomy Lt colon injuries - Temporary colostomy Other high risk pts - Diverting ileostomy with colocolostomy Rectal injuries – loop ileostomy/ sigmoid loop colostomy Accessible rectal injury – attempt primary repair with diversion Extensive rectal injury – End colostomy (Hartmann’s) Complications: Intra-abdo abscess, fecal fistula, infection, stomal complications
- 64. Genitourinary Tract 64 90 % Renal injuries managed conservatively Hematuria resolves in few days with absolute rest Operative intervention – Hypotension due to Renovascular injuries Destructive parenchymal injuries Persistent gross hematuria – embolization Urinoma – Percutaneous drainage Renal artery repair Success rates very low Image guided endostent placement can be attempted
- 65. Genitourinary Tract 65 Renorrhaphy Take vascular control for proper visualization Preserve renal capsule Collecting system is closed separately with absorbable sutures Preserved capsule is closed over collecting system repair Ureter injuries Primary repair with renal mobilization for tension relief Reimplantation (with psoas hitch) for distal ureter injuries Damage control – B/L ligation + Nephrostomy
- 66. Renorrhaphy 66
- 67. Genitourinary Tract 67 Bladder injuries Intraperitoneal injuries Running, single layer 3-0 absorbable monofilament suture Lap repair – if other injuries not needing repair Extraperitoneal injuries NOM with bladder decompression for 2 wks Urethral injuries Bridge the defect with Foley’s Elective repair for strictures later
- 69. ABDOMINAL COMPARTMENT SYNDROME Symptomatic organ dysfunction that results from increased intraabdominal pressure (IAP) Increased IAP is an under-recognized source of morbidity and mortality. 1-day point-prevalence observational trial conducted in 13 medical ICUs of six countries with 97 patients, 8% had IAP > 20mmHg. The incidence of ACS in trauma patients is estimated to be between 2 and 9 percent.
- 70. ABDOMINAL COMPARTMENT SYNDROME Massive volume resuscitation in the leading cause of ACS. Inflammatory states with capillary leak, fluid sequestration, inadequate tissue perfusion, and lactic acidosis can develop ACS. Gastric overdistention following endoscopy has resulted in ACS. ETIOLOGY
- 71. ABDOMINAL COMPARTMENT SYNDROME The IAP is usually 0 mmHg during spontaneous respiration Slightly positive in the patient on mechanical ventilation IAP increases in direct relation to body mass index. Supine hospitalized patients had a mean baseline value of 6.5 mmHg. The compliance of the abdominal wall limits the rise in IAP but increases rapidly after a critical IAP Critical IAP varies from patient to patient, based on abdominal wall compliance on perfusion gradient IAH often defined as IAP > 12mmHg Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall compliance and can be protective PATHOPHYSIOLOG Y
- 72. ABDOMINAL COMPARTMENT SYNDROME CLINICAL MANIFESTATIONS CENTRAL NERVOUS SYSTEM Intracranial pressure Cerebral perfusion pressure CARDIAC Hypovolemia Cardiac output Venous return PCWP and CVP SVR PULMONARY Intrathoracic pressure Airway pressures Compliance PaO2 PaCO2 Shunt fraction Vd/Vt GASTROINTESTINAL Celiac blood flow SMA blood flow Mucosal blood flow pHi RENAL Urinary output Renal blood flow GFR HEPATIC Portal blood flow Mitochondrial function Lactate clearance ABDOMINAL WALL Compliance Rectus sheath blood flow
- 73. ABDOMINAL COMPARTMENT SYNDROME 50 mL of sterile saline is instilled into the bladder via the aspiration port of the Foley catheter with the drainage tube clamped. An 18-gauge needle attached to a pressure transducer is then inserted in the aspiration port, and the pressure is measured. The transducer should be zeroed at the level of the pubic symphysis.
- 74. ABDOMINAL COMPARTMENT SYNDROME MANAGEMENT GRADING OF ABDOMINAL COMPARTMENT SYNDROME Grade Pressure (mmHg) Management I 10-15 Maintenance of normovolemia II 16-25 Volume administration III 26-35 Decompression IV >35 Re-exploration Abdominal Perfusion Pressure (APP): APP = MAP - IAP In one retrospective study, the inability to maintain an APP above 50 mmHg predicted mortality with greater sensitivity and specificity than either IAP or MAP alone .
- 75. ABDOMINAL COMPARTMENT SYNDROME OPERATIVE DECOMPRESSION Vacuum-assisted temporary abdominal closure device: Thin plastic sheet, a sterile towel, closed suction drains, and a large adherent operative drape. This dressing system permits increases in intra-abdominal volume, without a dramatic elevation in IAP.
- 76. ABDOMINAL COMPARTMENT SYNDROME ACS is a clinical entity caused by an acute, progressive increase in IAP. Multiple organ systems are affected, usually in a graded fashion. The gut is the organ most sensitive to IAH. Treatment involves expedient decompression of the abdomen. Pt already physiologically compromised Keep high degree of suspicion and a low threshold for checking bladder pressures to prevent the associated mortality SUMMARY
- 77. References ATLS Manual 9th Ed Schwartz Principles of Surgery, 10th Ed Sabiston Textbook of Surgery, 20th Ed Manual of Trauma Surgery, Dept of Surgery, AFMC, 2013 Trauma, Moore, 6th Ed 77