Recommandé
Contenu connexe
Tendances
Tendances (20)
Similaire à Abdominal Injuries Part 1.pptx
Similaire à Abdominal Injuries Part 1.pptx (20)
Plus de Makafui Yigah
Plus de Makafui Yigah (15)
Dernier
Dernier (20)
Abdominal Injuries Part 1.pptx
- 1. ABDOMINAL INJURIES PART 1 (16th JANUARY 2023) Dr. M. Yigah
- 2. Introduction • Trauma is the leading cause of death between ages 1 and 44 • The abdomen is third most injured region of the body. • Abdominal injuries accounts for 15 - 20% of all trauma deaths • Abdominal trauma is traditionally classified as either blunt or penetrating. • Morbidity and mortality from abdominal injuries are due haemorrhage and sepsis • It is usually associated with injuries of other regions of the body. • Missed or delayed diagnoses are the most common cause of death from these injuries
- 3. Epidemiology • Epidemiology of abdominal injuries varies across the continent • In Egypt it account for 82.7% of all trauma cases (Gad et al 2012) • 14.2% of all trauma cases in Mbarara hospital in Uganda (Ruhinda et al 2008) • Ghana • Ghana Medical Journal– 234 abdominal injuries were seen between 1983 and 1989 (Naaedar 1990) • 411 patients were seen with penetrating injuries in KBTH and KATH between 1998 to 2008 (Dakubo et al 2010) • KBTH – General Surgery Logs • 1772 cases in total were done between August and December • 5 Trauma laparotomies • Spleen was the most injured viscus – 3 cases • Small bowel and mesenteric injuries – 2 cases
- 4. Boundaries of the Abdomen
- 6. Classification of Abdominal Injuries • Non-penetrating abdominal Injuries • Damage to the abdomen and/or abdominal organs secondary to the impact of blunt forces applied across an abdominal region. • Forces can be localised to one region of the body or across a wide area. • Penetrating abdominal Injuries • Occurs when there is a full thickness violation of the abdominal wall which may or may not be associated with visceral injuries. • Visceral injury is more likely when the fascia is breached.
- 7. Blunt Injuries • Automobile accidents • Fall from heights • Impalement of blunt objects • Assaults – kicks and blows • Blast injuries • Sports injury Penetrating Injuries • Stab wound • Gunshot wound • RTA • Impalement of sharp objects • Flying objects • Falls from height
- 8. Frequency of Injured Organs Blunt Injuries Spleen – 26% Kidney – 24% Intestines – 16% Liver – 16% Other – 20% Penetrating Injuries Stab wounds • Liver (40%) • Small bowel (30%) • Diaphragm (20%) • Colon (15%) Gunshot wounds • Small bowel (50%) • Colon (40%) • Liver (30%) • Abdominal vascular structures 25%
- 9. Mechanisms of Abdominal Injuries 1. Blunt Abdominal Injuries • Deceleration forces – generates shearing forces that avulse structure near fix points • Crushing forces – compression of visceral between abdominal wall and vertebrae • Blow-out forces – sudden increase in intra-luminal pressures cause hollow viscus to rupture 2. Penetrating Abdominal Injuries • Construction of injuring agent – e.g., length of knife, calibre of bullet. • Energy behind injury – e.g., stabbing forces vs
- 10. Pathophysiology • Haemorrhage • Injury to solid viscera – early death if not managed efficiently • Injury to major abdominal vessel – immediate death • Sepsis • Spillage hollow viscus contents - chemical and bacterial peritonitis. • Death is usually slow.
- 11. ATLS Protocol • Primary survey • Airway and Cervical spine control • Breathing • Circulation and Control of Haemorrhage • Assessment of level of consciousness, Pulse rate and Volume, BP, Skin perfusion • Identify any source of external or internal bleeding • Venous access with 2 wide bore cannulae • Samples for baseline investigations – FBC, GXM, Clotting profile, Serum Lactate, Serum Amylase, • Administration of warmed crystalloids, blood and plasma • Disability – assessing level of consciousness, • Exposure and Environmental Control • Adjuncts of Primary Survey • ECG, Pulse Oximetry, ABG, NG tube, Urinary Catheter, • Chest X-ray, Cervical and Pelvic X-ray • FAST, eFAST, DPL
- 12. Categorization of Patients • Haemodynamically ‘normal’ • investigation can be completed before treatment is planned; • Haemodynamically ‘stable’ – • Investigation is more limited. • It is aimed at establishing whether the patient can be managed non-operatively, whether angioembolization can be used or whether surgery is required; • Haemodynamically ‘unstable’ – • Investigations need to be suspended as immediate surgical correction of the bleeding is required.
- 13. ATLS Protocol • Secondary Survey • Short Concise Relevant History (AMPLE) • Allergies • Medications currently used • Past illnesses/Pregnancy • Last meal • Events/Environment related to the injury • Speed and Type of collision (frontal, lateral, sideswipe, rear, rollover) • Types of restraints • Patient's position in vehicle • Fatalities at scene • Height of fall • Type of gun or knife used • Physical Examination • Head to toe
- 14. Evidence of Abdominal Injuries • Obvious penetrating instrument • Evisceration of bowel, omentum etc. • Ecchymosis on abdominal wall: Grey-Turner sign, Cullen sign, Seatbelt sign • Peritonism • Tenderness, guarding and Rebound tenderness • BS may be abolished • Tenderness on DRE • Balance sign – Dull percussion in the LUQ (Blood in subcapsular or extracapsular spleen) • Kehr sign - Left shoulder pain while supine; caused by diaphragmatic irritation
- 15. Cullen’s Sign Evisceration of Intra- abdominal Organs Seatbelt Sign Grey-Turner Sign Penetrating Agents
- 16. Investigations • Baseline labs • FBC • Grouping and Cross matching. • Coagulation profile, ß-HCG, • Amylase • X-rays - Chest, Cervical and Pelvic x-ray • It should not delay in resuscitation • Chest x-rays can show potentially life-threatening injuries • Pelvic X-ray – fracture responsible for haemoperitoneum • Abdominal X-ray – • Has been superseded by FAST • Can demonstrate trajectory of penetrating agent
- 17. FAST • Focused Assessment with Sonography for Trauma • Blood in the pericardial sac, hepatorenal fossa, splenorenal and POD. • Not to assess visceral injury • A positive FAST and Haemodynamically unstable patient is an indication for Exploratory Laparotomy
- 18. Diagnostic Peritoneal Lavage To detect haemorrhage, bowel and biliary contents in unstable patients Abdominal evaluation in stable patients in settings where FAST and CT are not available. • Relative contraindications • previous abdominal operations, • morbid obesity, • advanced cirrhosis
- 19. Positive DPL • Aspiration of 10ml or more of free blood. • RBC of >100000/ml. • Aspiration of GIT contents, vegetable fibers, or bile. • WBC >500/ml • Amylase > 19 IU/L • Alkaline phosphatase > 12IU/L • Bilirubin level - > 0.01mg/dL
- 20. CT Scan • Gold standard for evaluating solid organ blunt abdominal injury. • It is however time-consuming and requires a co-operative patient. • Used only in hemodynamically normal patients in whom there is no apparent indication for an emergency laparotomy • Can be used to used to detect and grade solid organ injuries (Based on the AAST) • Help quantify the volume of intra-peritoneal haemorrhage • Used to assess retroperitoneal and pelvic organ injuries
- 22. Laparoscopy To be done in stable patients only Applications • Screening: to exclude a penetrating injury with breach of the peritoneum. • Diagnostic: finding evidence of injury to viscera. • Therapeutic: used to repair the injury Still not fully developed
- 23. Indications for Exploratory Laparotomy 1. Blunt abdominal trauma with hypotension with • positive FAST or • clinical evidence of intraperitoneal bleeding, or • without another source of bleeding 2. Hypotension with an abdominal wound that penetrates the anterior fascia 3. Gunshot wounds that traverse the peritoneal cavity 4. Evisceration 5. Peritonitis 6. Free air, retroperitoneal air, or rupture of the hemidiaphragm 7. Contrast-enhanced CT that demonstrates • Ruptured gastrointestinal tract, renal pedicle injury, or • Severe visceral parenchymal injury after blunt or penetrating trauma
- 24. Trauma Laparotomy • Team Preparation 1. Assemble and coordinate the operating team: • Notify the emergency scrub team to create theatre space, prepare equipment and call other colleagues. • Inform the anesthetic team • Ensures there is an understanding of the available equipment and definition of role • Discussion of injury burden, time frame if getting knife to skin and agree on definitive vs DCS goals. • Request for likely equipment one will need • An open vascular set with vascular clamps • Multiple large abdominal swabs • Bowel stapler • Self-retainer retractors if the patient is obese • Long needle holders with desired sutures • Cell saver suction device • An energy device such as a Harmonic scalpel or LigaSureTM.
- 25. Trauma Laparotomy • Perioperative preparation • 2 large bore venous access • Foleys catheter and an NG tube passed • Blood products should be obtained • Temperature control of the room and the patient • Administration of perioperative antibiotics • Positioning and skin preparation • Supine position with arms fully abducted at 90o • Skin is prepared from the chin to the knees and between the posterior axillary lines • Draped from chine to above the knee (risk of hypothermia)
- 27. Trauma Laparotomy • Abdominal access • Bold midline incision from xiphisternum to pubis. • Use the scalpel (diathermy is time consuming) • Divide the falciform ligament if necessary. • Use a virgin territory if there are previous scars • Complete evisceration of small bowel • Securing haemostasis • Evacuate the liquid and clotted blood from all 4 quadrants • Deliver the small bowel in two large abdominal packs to the patients right • Systematically empirical pack the abdomen – • Liver, Right Paracolic gutter, Spleen and Left paracolic gutters and pelvis • Inspection and clamping of any bleeding mesenteric vessels. • Aortic clamping – in rapidly exsanguinating patients
- 29. Trauma Laparotomy • Exploring the abdomen • Run the gut from the ligament of Treitz to the rectum • Systematically remove the pack around the liver and asses its injuries. • Assess the gallbladder and the biliary tree • Palpate the right kidney • Carefully Inspect the spleen after removing the pack • Palpate the left kidney • Inspect the hemi-diaphragms • Enter and inspect the lesser sac through the left side of the greater omentum. • Mattox manoeuvre or Cattell–Braasch maneuver
- 31. Trauma Laparotomy • Choosing an operative profile a. Definitive repair of the injuries with formal abdominal closure b. Damage Control techniques and temporary abdominal closure • Factors to consider a. Pattern of injury – e.g., major vascular injury – definitive repair but a hollow viscus injury – DCS b. Overall trauma burden e.g., serious injury to another region (head injury) c. Operating room system and circumstances - small rural facility, limited trauma experience etc. d. Physiological insult a. Duration of hypotension, Realistic estimate of blood loss and transfusion requirements b. Onset of metabolic acidosis (pH< 7.3) and hypothermia – late indicators
- 32. Damage Control Surgery • Principles of DCS • Control of bleeding • Identification of injury • Control of contamination • Protection from further injury e.g., abdominal compartment syndrome
- 33. Trauma Laparotomy • Abdominal Wound Closure • Definitive Repair – Standard closure as with Laparotomy • Dictated by level of contamination of wound • Damage Control Surgery (DCS) – Closure is temporary with 4 objective • Containment of viscera, • Control of abdominal secretion, • Maintenance of pressure on tamponaded areas, and • Optimization of the likelihood of eventual closure • Techniques – Running sutures, Bogota bag, towel clips, Ioban, Vacuum closures
- 35. Management after DCS • Continued resuscitation and restoration of normal physiology • Reversal of Hypothermia • Nurse patient in a warm room, • Administer warm intravenous fluid and blood products, • Application of external warming devices (Bair Hugger). • Reversal of acidosis • Correction of shock will correct metabolic acidosis • Patient’s ability to normalize lactate is strongly correlated with survival • Correction of Coagulopathy • Correction of acidosis and hypothermia corrects it • Replacement of blood products • Recent – use of recombinant factor VIIa
- 36. Abdominal Compartment Syndrome • Causes • bowel wall oedema • Third space fluid loss • Intra-abdominal packing • Diagnosis • Intra-vesical pressure with foleys catheter connected to a transducer or manometer • Treatment • Management is dependent of pressure levels • 10-15cm/H2O Maintain euvolaemia • 16-25cm/ H2O Hypervolaemic resuscitation • 26-35cm/H2O Decompress • > 35cm/ H2O Decompress/re-explore abdomen looking for bleeding
- 37. Reoperation after DCS • Should be done within 48 – 72hrs before the onset of SIRS • It involves • Removal of abdominal packs • Confirming haemostasis • Inspection of abdomen for any missed injuries • Restoration of intestinal integrity and abdominal wound closure.
- 38. END OF PART 1
Notes de l'éditeur
- The abdomen w part of the trunk between the thorax and the pelvis. Broad spectrum of abdominal injuries considering the numerous viscera that can injures.
- In sub-Saharan Africa, the risk of death from trauma is highest in those aged 15 to 60 years This risk is higher than in any other region of the world. Naaedar – 65.9%
- Abdomen – Flexible dynamic container Anterior aspect– nipple line to the groin crease and pubis and AAL laterally Lateral aspect – from ALL to PAL and 6th ICS to Iliac Crest Posterior – PAL to PAL and from Tip of Scapulae to Iliac Crest
- Organs can be classified as being solid or hollow Upper - Liver and Spleen, Stomach and Transverse colon Lower - Jejunum and ileum, ascending, descending and sigmoid colon, reproductive organs Pelvis - Rectum, bladder iliac vessels and internal reproductive organs Retroperitoneum - duodenum, pancreas posterior part of asc and desc colon, abdominal aorta, IVC, kidneys and ureter
- Blunt Abdominal Trauma – poorer prognosis due to the concealed nature Multiple organs may be injured The damage may be concealed due to the subtle clinical features Unrecognized, abdominal trauma is a frequent cause of preventable death
- Deceleration - solid visceral organs and vascular pedicles at relatively fixed points of attachment. Crushing - Intra-abdominal contents can be crushed between the anterior abdominal wall and the vertebral columns. Solid viscera are more vulnerable to crush injuries. Blowout injuries There is an increase in intraluminal pressure of a segment of a hollow viscera causing it to rupture.
- Internal haemorrhage are often identified by physical examination and imaging (FAST, Pelvic, CXR) or DPL Primary survey is directed at identifying major intra-abdominal haemorrhage Secondary survey is essential to pick up further bleeding following the restoration of a normal blood pressure. Abdominal Injuries are often associated with other injuries – Injuries to the airways, intra-thoracic structures generally take precedence over abdominal. Never pull out a knife wound The conscious state of the patient is a way of assessing the circulatory function and its important for obtaining further information from the patient. Identify any source of external or internal bleeding Physical examination Imaging – X-ray, FAST Diagnostic Peritoneal Lavage
- Overzealous fluid resuscitation cannot replace Secondary survey is essential to pick up further bleeding following the restoration of a normal blood pressure.
- It does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are under way, and improvement of the patient’s vital functions has been demonstrated. If there are more personnel, the secondary survey can be started whiles the rest continue with the resuscitation. Patient may be unconscious, intoxicated or shock – history from ER team, by standers etc.
- For both primary and secondary survey Never pull out the instruments (avoid unnecessary movements) Peritonism – intoxicated, head injuries, retroperitoneal injuries
- Elevated levels points to possibility of pancreatic injury Also elevated in traumatic rupture of the stomach, duodenum or small bowel. Chest x-rays can show potentially life-threatening injuries that require treatment or further investigation, and pelvic films can show fractures of the pelvis that may indicate the need for early blood transfusion. These films can be taken in the resuscitation area with a portable x-ray unit, but not when they will interrupt the resuscitation process (n FIGURE 1-5). Do obtain essential diagnostic x-rays, even in pregnant patients
- It can be done at the bedside whiles being resuscitated It can be repeated to detect progressive hemoperitoneum Disadvantage About 250ml of fluid is needed to detect Cannot reliably grade solid organ or hollow viscus injuries Operator dependent Cannot assess retroperitoneal structures well.
- Prerequisite - Gastric and Urinary Decompression to avoid complications. An open, semi-open, or closed (Seldinger technique) An infra-umbilical approach is used Supra-umbilical approach is used cases of pelvic fractures and Applications
- It used to be the gold standard Now been superseded by FAST and CT Scan
- CT is a time-consuming. That are difficult to assess with a physical examination, FAST, and DPL It is used as the basis for managing a patient non-operatively
- Selective digital subtraction angiogram of the celiac axis showing the intra-peritoneal contrast 'blush' in the spleen, confirming active bleeding. Selective splenic angiogram immediately post proximal embolization demonstrating perfusion defects. Contrast extravasation is no longer present.
- Drawback – high false negative with small bowel injuries
- Bleeding from the stomach, rectum, or genitourinary tract following penetrating trauma
- Core Mission – Stop the bleeding If patient is not bleeding – then identify and repair
- Prepare for the worst case scenario: unplanned thoracotomy or required access to the groin. Preventing hypothermia – Bair Hugger and warm the NS
- This sequence reflects the underlying logic and priorities of the procedure. Modified according to clinical circumstances IF there is no significant bleeding there is no need to pack . If there is major blood vessel bleed – then temporary haemostasis merges with definitive repair
- Don’t waste time chasing incisional bleeder tly pack the abdomen without attempting to precisely identify the injuries (hence the term “empirical” packing). It is worth mentioning that ongoing surgical bleeding will not be amenable to packing and must be addressed at the time of the initial laparotomy. If the general picture is of overwhelming bleeding and there is simply no means of getting other temporary control or immediate access to the specific bleeding, then we advocate aortic control.
- Mattox manoeuvre (Left Medial Rotation) or Cattell–Braasch maneuver (Right Medial Rotation)
- Mattox - suprarenal aortic segment in the presence of a central retroperitoneal hematoma Cattel-Brasch manoeuvre Zones of the retroperitoneum visualized at the time of laparotomy. Zone 1 - central vascular structures, such as the aorta and vena cava. Zone 2 includes the kidneys and adjacent adrenal glands. Zone 3 describes the retroperitoneum associated with the pelvic vasculature
- even the clinical suspicion of such trauma (e.g., unequal pupils) “forced” bailout actually means that the surgeon is trying to correct a previous error in judgment and should have bailed out long ago.
- It is a resuscitative procedure
- with perforated, nonadherent plastic drape over viscera, followed by moistened towel or dressing, on top of which are laid two closed-suction drains (Jackson–Pratt) that are tunneled subcutaneously and brought out through separate stab incisions. A large adherent drape is lastly used to create an air-tight seal and relatively sterile environment. W
- The goal of the immediate post-damage-control laparotomy period is correction of the abnormal physiology.
- The goal of the immediate post-damage-control laparotomy period is correction of the abnormal physiology.
- [ Is this the definitive procedure ] [ Where will colostomies be placed ]