Download - Nath abdominal trauma
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Abdominal Trauma
Nat Krairojananan M.D., FRCST
Department of Trauma and Emergency Medicine
Phramongkutklao Hospital
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overview
• Quick review abdominal anatomy
• Review of mechanism of injury
• Review of investigation
• management
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Anatomy of abdomen
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External Anatomy
Anteriorabdomen
Flank
Back
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Visceral organ
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visceral organ
Pelvic cavity
Retroperitoneal space
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Abdominal injuries
• No.1 Preventable cause of death
• Unrecognized
• Closed spaces
• Multisystem / multiple organs
• Need investigations
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ATLS protocol
Primary survey
A B C D E
Adjunct to primary survey
A B C D E
Maintain circulation Stop / seek for bleeding
Monitoringinvestigations
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Investigations for abdominal trauma
• FAST
• DPA (DPL)
• CT scan
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FAST: Focused Abdominal Sonography for Trauma
Advantage
• Good sensitivity
• Easy to use
• Repeatable
• No radiologic exposure
• Really excellent test?
Disadvatage
• Operator dependent
• Poor evaluation for hollow viscus and retropertoneal injury
• Negative FAST?
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DPL: Diagnostic Peritoneal Lavage
Advantage
• High sensitivity and specificity
• Hollow viscus injury detection
Disadvantage
• Invasive
• Poor evaluation for retropertoneal injury
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DPL: Diagnostic Peritoneal Lavage
Indications
• Equivocal abdominal sign
• Unexplained shock
• Unevaluable abdominal status
– Alcohol / drug
– Head / spinal injury
– unconscious
Interpretation
DPL positive in
• Receive 10 ml of gross blood
• Cell count: – RBC > 100000
– WBC > 500
• Biochemistry: – amylase > 175 iU/ml
• Microscopic: – food particle, bile, bacteria
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DPL
• False positive rate in RBC count 11%, esp. in low RBC cell count
• False positive rate in WBC count: late DPL
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Computer Tomography
• Great sensitivity and specificity
• Detect hollow viscus, retroperitoneal injury
• Grading organ injury non-operative management plan
• Blunt VS penetrating
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Limitation of CT scan
• Some hollow viscus and mesenteric injury
• Patient’s hemodynamic status
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Type of injury
• Blunt injury
• Penetrating injury
• Blast injury
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Algorithm for the management of blunt abdominal trauma
Blunt abdominal
trauma
Clinically evaluable
Diffuse abdominal tenderness
OR
No diffuse abdominal tenderness
Hemodynamic stable
Hemodynamic labile
Clinically unevaluable
Hemodynamic stable
CT +
OR or NOMx
CT -
observation
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Hemodynamically
labile
FAST +
OR
FAST -
Other causes or hemodynamically
labile present
Further evaluation/
resuscitation
No other causes or hemodynamically
labile present
DPA +
OR
DPA -
Further evaluation/
resuscitation
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Hemodynamicallystable
FAST +
CT +
OR / NOMx
CT -
observation
FAST -
CT?
observation
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Algorithm for the management of penetrating abdominal trauma
Penetrating abdominal
trauma
Diffuse abdominal
tenderness +
OR
Diffuse abdominal
tenderness -
Hemodynamicallystable
Hemodynamicallylabile
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Hemodynamicallystable
Left thoracoabdominalor right anterior
thoracoabdominalinjury
laparoscopy
No left thoracoabdominal
injury
GSW
OR?
SW
observation
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Hemodynamicallylabile
Other cause of hemodynamically
lability present
DPA +
OR
DPA -
Further evaluate/ resuscitate
No other cause of hemodynamic
lability
OR
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Investigation for penetrating injury with hemodynamic stable
Location investigation
Thoracoabdomen CT scanthoracoscopylaparoscopy
Anterior abdominal wall LWEFAST, DPLCT
Back and flank CT
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Options of evaluationin penetrating injury
Investigation % Sensitivity % Specificity
Physical Examination 95-97 100
Local Wound Exploration
71 77
DPL 87-100 52-89
FAST 46-85 48-95
CT scan 97 98
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Blast Injury
Primary Secondary Tertiary Quaternary
Blast wave Shrapnel Blast wind Other consequences
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Indication for surgery
• Hemodynamic unstability
• Peritonitis
• Inability to
• examine patient
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Non-operative treatment
• Solid organ injury only
• Hemodynamically stable
• No peritonitis
• Capable for serial examination immediate investigation and celiotomy if needed
• Multiple / combined injury
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Missed abdominal trauma
• Intraabdominal organs
– Diaphragmatic injury
– Hollow viscus injury
– Retroperitoneal injury
– Mesenteric injury
• Other combined injury
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Combined injuries
Head and abdominal injuries 5.7%
Challenges:
• Reliability for abdominal evaluation
• Timing of CT evaluation of the head
• Severe head trauma in non-operative Mx of abdominal solid organ injury
• Major intraabdominal injury with severe blood loss leads secondary brain injury
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Algorhitm for the management of combined head / abdominal trauma
Combined head and abdominal
injury
Hemodynamicallystable
GCS < 12
Localizing sign
CT before laparotomy
GCS > 12
No localizing sign
Laparotomy
before CT
Hemodynamicallylabile
GCS < 9
Localizing sign
Laparotomy
Then BH / ICP
Post op CT scan
GCS > 9
No localizing sign
Laparotomy
Follow by CY scan
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Pelvic fracture
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Pelvic Fractures
Mechanism
• AP compression
• Lateral compression
• Vertical shear
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Pelvic Fractures
Assessment
• Inspection: Leg-length discrepancy, external rotation
• Pelvic ring: Pain on palpation of bony pelvic ring
• Palpate prostate
• Associated injuries
• Pelvic bleeding
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Pelvic Fractures
Emergency Management
• Fluid resuscitation
• Determine if open or closed fracture
• Determine associated perineal /GU injuries
• Determine need for transfer
• Splint pelvic fracture
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Splinting fractured pelvis
• Pelvic wrapping
• Pelvic C-clamp
• External fixator
• ORIF
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Special considerations
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Case I: 32 year-old female
• GA 37 weeks
• G2P1001
• Patient model for medical student
• On the way home: MCA
• Pain on movement both hip joints
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Pelvic wrapping
Roll on her left side
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External fixator
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Case II: 37 year-old male
• Short gun wound abdomen
• Unstable vital signs on arrival
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Case III: 48 year-old male
• gunshot wound ? At posterior right tight
• Unstable vital signs on arrival
• No abdominal sign on arrival
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Conclusion
ATLS initial assessment
• Primary survey
• Adjunct to primary survey
Select appropriate investigation(s) for the injury