Resuscitation & abdominal trauma

1. Resuscitation & Abdominal
trauma
Presenter : Muhammad Afif
Anis Zarina
Supervisor : Dr Wazir

2. Outline
DEFINITION AND INTRODUCTION
ASSESSMENT & RESUSCITATION
DEFINITIVE CARE
TAKE HOME MESSAGES

3. DEFINITION AND INTRODUCTION
• TRAUMA – cellular disruption caused by
environmental energy / physical force
• 6th
leading cause of death worldwide(10% of
cases)
• Leading cause of death in those aged 5 to 40
years
• Majority of trauma cases is due to road traffic
accidents (70.1%)

4. Trauma related death has a
trimodal distribution
A) Death due to massive
injuries. Seconds to
minutes.
B) Death due to
hemorrhage. Hours.
C) Death due to late
complications of
trauma. Days to weeks.
*golden hour – in the 1st
hour, 30% of death
takes place

5. Lethal triad of death in trauma
Severe haemorrhage →
hypovolemic shock →
Hypothermia + coagulopathy
+ acidosis
3 factors aggravate each other
in a vicious cycle further→
bleeding intractable shock→
→ death

6. Assessment and resuscitation
• Primary survey with concurrent resuscitation.
• Requires a team of doctors, nurses, assistant
medical doctors and attendants.
• Must be lead by a team leader.
• Secondary survey with concurrent resuscitation.
• Reassessment and on going resuscitation while
reviewing investigations.

7. Primary Survey
• A = Airway maintenance with cervical protection
– intubate if necessary.
• B = Breathing and ventilation – Look for signs of
respiratory distress and SPO2.
▫ Non invasive or invasive oxygen therapy with
relief of life threatening conditions eg tension
pneumothorax.

8. • C = Circulation with hemorrhage control
▫ 2 large bore 16 Gauge branula, CBD, CVP
▫ IV crystalloids 30ml/kg run fast
▫ Stop external bleeder
▫ Colloids and blood products.
▫ Aim MAP 65mmHg
• D = Disability ,neurological status
• E = Exposure / environmental control

9. Evaluation of fluid resuscitation
• The return of normal blood pressure, pulse
pressure and pulse rate
• Improvements in CNS status and skin
circulation .
• Urine Output : 0.5-1ml/kg/h
• CVP
• Acid base balance
▫ Persistent metabolic acidosis is usually due to
inadequate resuscitation or ongoing blood loss.

10. After fluid bolus is given..
Rapid response Transient response No response
Vital signs Return to normal Transient
improvement
Remain abnormal
Estimated blood
loss
Minimal (10-20%) Moderate and
ongoing (20-40%)
Severe (>40%)
Need for more
crystalloid
Low High High
Need for blood Low Moderate to high Immediate
Blood preparation Type and cross
match
Type – specific Emergency blood
release
Need for operative
intervention
Possibly Likely Highly likely
Need for immediate
surgical
intervention
No No Yes

11. Transient or non responder
• Most common: ongoing internal bleeding
- clinically : more pallor, persistent
tachycardic, tachypnea, abd distension
- FAST scan
- Aggressive fluid resuscitation (using 3:1 rule)
- Blood transfusion : 2pint pack cell
*consider DIVC regime

12. Secondary Survey
• Follows the primary survey
• Complete history including AMPLE
• Complete head -to-toe examination
• Reassessment of response to resuscitation.

13. Examination
Inspection Palpation Auscultation
Distended Tenderness Bowel sounds
-absent
-in thorax
Abrasion Guarding
Laceration Rigidity
Cullen’s, Grey turner’s,
Kehr’s sign
Mass
Gross hematuria PR – high riding prostate
Hematoma or bruises

14. Cullen’s sign Grey turner’s sign
Kehr’s sign

15. Investigations
• Serial FBC, RP, PT/INR, ABG, Serum amylase
• FAST US
• X-ray chest and abdomen
• USG Abdomen
• CT scan

16. Focused Assessment with Sonography in
Trauma (FAST)
• To detect hemoperitoneum & pericardial effusion
• Sensitivity 86- 99%
• Four different views:
-Pericardiac
-Perihepatic
-Perisplenic
-Peripelvic

17. Advantages of FAST
• Can detect 100 mL of blood
• Rapid , accurate, portable, reproducible
• Cost effective, non invasive, no radiation
• Eliminates unnecessary CT scans
• Helps in management plan

18. Plain X-ray chest & Abdomen
CXR:
• Free air under diaphragm
• NG tube or bowel loops in the thoracic cavity
• Elevation of both or single diaphragm
• Lower ribs fractures
AXR:
• Ground glass appearance-massive hemoperitoneum
• Obliteration of psoas shadow-retroperitoneal bleed

19. CT scan
• Gold standard
• High sensitivity and specificity-95%
• Provides excellent imaging of solid and hollow
organs, retroperitoneum, genitourinary system
(able to grade) and hemo/pneumoperitoneum.
• Determines the source of bleeder.
• Can reveal other associated injuries eg vessels.
• Only in haemodynamically stable patients.

20. ABDOMINAL TRAUMA

21. MECHANISM OF INJURY
Blunt trauma Penetrating injury
Fall from height Stab wound
MVA Gunshot wound
Domestic injury
Sport injury
Contact injury
Child abuse

22. Abdominal injuries
• Intraperitoneal
• Solid, hollow, mesentery
• Retroperitoneal
• Abdominal wall (hematoma) esp in warfarinized
or hemophilia patients after minor trauma.

23. Intraperitoneal
• Solid organs
▫ Spleen(40-55%)
▫ Liver(35-45%)
• Hollow organs
▫ Gastric, bowel, bladder or GB perforation
▫ Penetrating injury
• Mesentery (bowel ischaemia)

24. Retroperitoneal
• Pancreas (10-20%) – traumatic pancreatitis
• Vascular(5-10%) – major vessels
• Kidneys(5%)

25. Indications for laparotomy
• Blunt abdominal trauma + hypotension +
positive FAST or clinical evidence of
intraperitoneal bleeding
• Penetrating trauma : eg : Gunshot or abdominal
evisceration
• Peritonitis
• Free air, retroperitoneal air or rupture of
hemidiaphragm after blunt trauma
• Organ specific injury - on CT scan

26. Splenic injury
• 20% due to left lower rib fractures
Conservative Management:
▫ Hemodynamic stable
▫ Negative abdominal examination
▫ Absence of contrast extravasation in CT
▫ Subcapsular Hematoma, Laceration <3cm
• Serial abdominal examination and CT scan.
• Success rate of conservative Mx >80%

28. Operative management
• Splenorrhaphy with serial monitoring.
• Total Splenectomy and vaccination.
• Success rate of splenic salvage procedure is 40-
60%.
• Others – partial splenectomy, total splenectomy
with autotransplantation.

29. Liver injury
• Largest organ - 2nd
most commonly injured
• 85% with blunt hepatic trauma are stable
• CT – main stay of diagnosis in stable patient
• Most treated conservatively
• Watch out for on going bleed, hepatic necrosis,
infected billoma, biliary tree injuries.

31. Conservative management
• Haemodynamically stable
• No other intra abdominal injury require surgery
• < 2 units of blood transfusion required in 6
hours
• Hemoperitoneum <500ml on CT

32. Operative management
• Liver packing
- Bleeding can be stopped
- Pack removed after 48hr
• Pringle’s maneuver
- Direct compression of the portal triad
(digitally or soft clamp) to control the inflow
• Lobar Resection
• Liver Transplantation

33. Renal injury
• Clinically not suspected & frequently overlooked
• Clinical - Shock, hematuria & pain over the loin
• Urine: gross or microscopic hematuria
• CT scan – Grading

35. Management
• 85% of blunt renal trauma can be manage
conservatively.
• Indications for nephrectomy
▫ Hemodynamic instability
▫ Grade 5 renal injury
• Risk of dialysis should be explained if planned for
nephrectomy.

36. Take home messages
• Primary survey and resuscitation goes hand in
hand. It’s an ongoing process.
• Coagulopathy, hypothermia, and worsening
metabolic acidosis are lethat triad that need to
be watched out for in trauma patients
• Fluid resuscitation is vital and evaluation of it is
important.
• Negative FAST scan cannot exclude possibility of
significant intraabdominal injury if clinically is
indicated.

37. • CT scan is gold standard to diagnose
intraabdominal injury in hemodynamically
stable patient.
• 20% of splenic injury is due to lower rib
fractures
• 85% with blunt hepatic trauma are stable
• 85% of blunt renal trauma can be manage
conservatively

38. References
• ATLS for Doctors, 9th
edition
• Bailey & Love Short Practice of Surgery, 25th
edition
• http://www.surgeons.org.uk/advanced-trauma-life-s
• Clinical companion in surgery

39. •Thank you!