abdominal injuries
DESCRIPTION
Abdominal injuries. Yoram Klein MD. Introduction. Suture repair of bowel - the 15th century. Routine exploration not employed until WW I. – mortality 70-75%. WW II – mortality 50%. Introduction. Diagnostic challenge. Importance of prompt management (?!). - PowerPoint PPT PresentationTRANSCRIPT
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Abdominal injuries
Yoram Klein MD
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Introduction
Suture repair of bowel - the 15th century. Routine exploration not employed until
WW I. – mortality 70-75%. WW II – mortality 50%.
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Introduction
Diagnostic challenge. Importance of prompt management (?!). Evolution in surgical management:
Damage control. Staged repair.
Colo-rectal repair. Duodenal repair.
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Decisions
What is the systemic condition? Is there an abdominal injury? Can the systemic condition be related to
the abdominal injury?
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What is the systemic condition?
Oxygenation. Hemodynamic stability. Neurological status.
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Is there an abdominal injury?
Mechanism of injury. Physical examination. FAST. Plain X-ray. CT. DPL.
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Physical examination
Blunt Hemodynamic
status. Abdominal wall
hematoma. Seat-belt sign. Peritoneal irritation. GI bleeding. Confounding factors.
Penetrating Hemodynamic
status. Location of the
wound. Evisceration. Peritoneal irritation. GI bleeding. Confounding factors.
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FASTFocused Assessment Sonography for
Trauma Advantages
Free fluid in the peritoneal or pericardial cavity?
Quick. Bedside. Repeatable.
Disadvantages False sense of
security. Retoperitoneum. Hollow viscous injury Penetrating trauma. User dependant.
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Plain X-ray
Blunt CXR. Pelvic.
Penetrating CXR. KUB in GSW.
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CT
Blunt The gold standard. Hemodynamic
stability. Normal FAST?
Penetrating RUQ low-energy
missiles. Triple-contrast for
flank and back wounds.
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DPL
Blunt Free fluid with no
organ injury in the CT. Patient’s examination unreliable.
Discrepancy between FAST and physical finding.
Penetrating Violation of the
anterior abdominal fascia --- stab wounds.
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Emergency laparotomy
Hemodynamic instability and abdominal injury. Hemodynamic instability and positive FAST. Diffuse peritoneal irritation. Significant evisceration. Imaging study suggesting hollow viscous
injury. GI bleeding.
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Management of penetrating injuryGSW
85% need surgical repair. Low energy RUQ. Tangential wounds.
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Management of penetrating injurystab wounds
Anterior abdomen local wound exploration. Violation of anterior fascia – DPL.Flank and back Triple contrast CT.Left thoraco-abdominal Surgical evaluation of the diaphragm.Right thoraco-abdominal CT.
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Management of blunt injury
CT. Free fluid with no organ injury in the CT.
Patient’s examination unreliable --- DPL. If signs of arterial bleeding - angiogram?
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Hollow viscous injuries
Diagnostic challenge. Importance of prompt management (?!). Evolution in surgical management:
Damage control. Staged repair.
Colo-rectal repair. Duodenal repair.
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Evolution in surgical management
Non-operative management. Damage control. Staged repair. Colo-rectal repair. Duodenal repair.
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Non-operative treatment
No indication for emergency surgery.
Spleen – OPSI in pediatric surgery.
Liver – non bleeding CT diagnosed injuries.
Penetrating injuries – good outcome with stable patients and unavailable OR.
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Damage control
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Physiological failure
On-going coagulopathy
acidosis hypothermia
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Damage control
Bleeding control. Contamination
control. Temporary
abdominal closure.
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Damage control
Bleeding control. Contamination
control. Temporary
abdominal closure.
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Damage control
Bleeding control. Contamination
control. Temporary
abdominal closure.
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Surgical approach
Hemorrhage control. Primary exploration and temporary control of
spillage. Thorough exploration and definitive spillage
control. Irrigation.------------------------------------------ Reconstitute continuity. Definitive abdominal closure.
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