Abdominal trauma

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Abdominal trauma

• Dr.L.Bahadorzadeh

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• The abdomen is frequency injured after both
  blunt and penetrating trauma.
• Approximately 25 of all trauma victims will
  require an abdominal exploration.

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• Physical examination of the abdomen is
  unreliable in making intra abdominal injuries.
• Drugs, alcohol, and head and spinal cord
  injuries complicate physical examination.
• It may also be impractical in patients
• who require general anesthesia for the treatment
  of other injuries.

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Mechanism of injury

• Blunt trauma secondary to motor vehicle
  accidents,falls..., remain the most frequent
  mechanisms of abdominal injury.
• Penetrating abdominal wounds are usually caused
  by either gunshot or stab wounds or less shotgun.

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Diagnosis

• ? The history of the traumatic events
• ? History and physical examination on arrival
• ? Diagnostic modality
• The test of choice will dependent on the
  hemodynamic stability of the patient the
  severity of associated injuries.

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unstable stable
Fast US/DPL CT/US If emergency DPL Blunt trauma
OR Wound explore/DPL Penetrating trauma
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Plain Radiographs

• ? C.X.Ray
• ? Intravenous pyelography
• ? Pelvic Radiography

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Diagnostic peritoneal lavage

• ? Indications
• equivocal pulmonary embolism
• Unexplained shock or hypotension
• Altered sensorium(closed head inj,drugs)
• General anesthesia for extra abdominal
  procedures
• Cord injury
• ? Contraindications
• Clear indication for exploratory laparatomy
• Relative
• Previous exploratory laparatomy
• Pregnancy
• obesity

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DPL

• ? Standard criteria for a positive DPL
• Aspiration of at least 10 ml gross blood
• A bloody lavage effluent
• A RBC count greater than 100000/mm³
• A WBC count greater than 500/mm³
• An amylase value greater than 175 IU/dl
• The detection of bile,bacteria,or food fibers

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• Sabiston concluded that
• Patients sustaining stab wounds can be safely
  discharge home
• if the RBC count is less than 1000 provided that
  they are hemodynamically stable have no clear
  indication based on physical examination for
  operative intervention.

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Ultrasound

• ?Advantages
• Non invasive
• Doesnot reqiure radiation
• Useful in the resuscitation room or
  emergency department
• Can be repeated
• Used during initial evaluation
• Low cost
• ? Disadvantages
• Examiner dependent
• Obesity
• Gas interposition
• Lower sensitivity for free fluid lt500 ml
• False negative
• retroperitoneal and hollow viscus
  injuries

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- Sono in abdominal trauma
Work up OR penetrating
NO-work up CT blunt
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Abdominal CT

• ? Indications
• Blunt trauma
• Hemodynamic stability
• Normal or unreliable physical examination
• Mechanismduodenal and pancreatic trauma
• ? Contraindications
• Clear indication for exploratory laparatomy
• Hemodynamic instability
• Agitation
• Allergy to contrast media

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• In CT
• if contrast medium extravasation is seen in
  minor hepatic and splenic injury an exploratory
  laparatomy or more recently angiography and
  embolization are indicated.

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• The diagnostic approach to penetrating and blunt
  abdominal trauma differs substantially.
• As a rule, little preoperative evaluation is
  required for firearm injuries that penetrate the
  peritoneal cavity, because the chance of internal
  injury is over 90 and laparotomy is mandatory

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• Anterior truncal GSWs between the fourth
  intercostal space and the pubic symphysis, whose
  trajectory by x-ray or entrance/exit wound
  suggests peritoneal penetration, should be
  operated on.

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• GSWs to the back or flank are somewhat more
  difficult to evaluate.
• If in doubt, it is always safer to explore the
  abdomen than to equivocate when the depth of
  penetration is uncertain.

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• SWs that penetrate the peritoneal cavity are
  less likely to injure intra-abdominal organs.
• Anterior and lateral SWs to the trunk should be
  explored under local anesthesia in the ED to
  determine whether the peritoneum has been
  violated.
• Injuries that do not penetrate the peritoneal
  cavity do not require further evaluation.

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• SWs to the flank and back are more difficult to
  evaluate.
• Some authorities have recommended a
  triple-contrast CT to detect occult
  retroperitoneal injuries.

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• SWs to the lower chest present a unique
  diagnostic opportunity.
• Confirmation of diaphragm penetration by
  palpation is an indication for laparotomy.
• when a hole is not palpable, a DPL should be
  performed.
• A RBC count in the effluent of more than 10,000
  is considered positive when evaluating for a
  diaphragmatic injury.
• For RBC counts between 1000 and 10,000,
  thoracoscopy should be considered.

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• Blunt abdominal trauma is currently evaluated by
  US in most major trauma centers, with CT in
  selected cases to refine the diagnosis.
• US performed by a surgeon in the ED.
• US is used in specific anatomic regions
  (e.g.,Morison's pouch, the left upper quadrant,
  and the pelvis) to identify free intraperitoneal
  fluid
• Although this method is exquisitely sensitive
  for detecting intraperitoneal fluid collections
  larger than 250 mL, it is relatively poor for
  staging solid organ injuries.
• DPL is still appropriate for patients whose
  condition cannot
• be explained by US.

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Emergent Abdominal Exploration

• ? All abdominal explorations in adults are
  performed using a long midline incision because
  of its versatility.
• Liquid and clotted blood is rapidly evacuate
• with multiple laparotomy pads and suction.
  Additional pads are then placed in each quadrant
  to localize hemorrhage, and the aorta is palpated
  to estimate blood pressure.

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• If exsanguinating hemorrhage is encountered upon
  opening the abdomen, it is usually caused by
  injury to the liver, aorta, inferior vena cava,
  or iliac vessels.
• If the liver is the source, the hepatic pedicle
  should be immediately clamped
• (a Pringle maneuver) and the liver compressed
  posteriorly by tightly packing several laparotomy
  pads between the hepatic injury and the underside
  of the right anterior chest wall.(fig.1)

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• If exsanguinating hemorrhage originates near the
  midline in the retroperitoneum, direct manual
  pressure is applied with a laparotomy pad and the
  aorta is exposed at the diaphragmatic hiatus and
  clamped.
• The same approach is used in the pelvis except
  that the infrarenal aorta can be clamped.
• venous injuries are not controlled with aortic
  clamping. A helpful maneuver in these instances
  is pelvic vascular isolation.(fig2)

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• For stable patients with large midline hematomas,
  clamping the aorta proximal to the hematoma is
  also a wise precaution.
• Many surgeons take a few moments, once
• overt hemorrhage has been controlled, to identify
  obvious sources of enteric contamination and
  minimize further spillage.
• This can be accomplished with a running suture or
  with Babcock clamps.

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• In blunt trauma, organs that cannot yield to
  impact by elastic deformation are most likely to
  be injured. The solid organs,liver, spleen,
  kidneys, are representative of this group.
• For penetrating trauma, organs with the largest
  surface area are most prone to injury (i.e., the
  small bowel, liver,and colon).

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• bullets and knives usually follow straight
  lines,adjacent structures are commonly injured
  (e.g., the pancreas and duodenum).
• Penetrating trauma is not limited by the elastic
  properties of the tissue, and vascular injuries
  are far more common.

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• All abdominal organs are systematically examined
  by visualization,palpation, or both.
• Missed injuries
• In penetrating trauma failure to explore
  retroperitoneal structures such as the ascending
  and descending colons, the second third portion
  of the duodenum, and ureters.
• Injuries of the aorta or vena cava may be
  temporarily tamponaded by overlying structures.
• Blunt abdominal injuries of the pancreas,
  duodenum, bladder, and even the aorta can be
  overlooked.

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Liver
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Liver

• Techniques for the temporary control of
  hemorrhage
• ? Manual compression (fig3)
• ? Perihepatic packing (fig3)
• ? The Pringle maneuver (fig3)
• ? Tourniquet
• ? Lin liver clamp

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liver

• Special techniques for controlling hemorrhage
  from juxtahepatic venous injuries
• ? Hepatic vascular isolation with clamps,
• ? The atriocaval shunt (fig4)
• ? The Moore-Pilcherer balloon

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• If massive venous hemorrhage is seen
• from behind the liver, and if reasonable
  hemostasis can be achieved with perihepatic
  packing, the patient can be transferred to the
  interventional
• radiology suite, where hemorrhage from arterial
  sources are embolized and stents are placed to
  bridge venous injuries

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• Numerous methods for the definitive control of
  hepatic hemorrhage developed.
• ? Minor lacerations may be controlled
• with manual compression applied directly to the
  injury site.
• ? electrocautery
• ? Microcrystalline collagen
• ? Topical thrombin
• ? Fibrin glue
• ? Suturing of the hepatic parenchyma
• (lacerations less than 3 cm in depth)

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• ? Venous hemorrhage due to penetrating wounds
  that traverse the central portion of the liver
  can be managed by suturing the entrance exit
  wounds with horizontal mattress sutures.
• ? Hepatotomy with selective ligation of bleeding
  vessels is an important technique usually
  reserved for transhepatic penetrating
  wounds.(fig5)

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• ? Hepatic arterial ligation may be appropriate
  for patients with recalcitrant arterial
  hemorrhage from deep within the liver.

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• the subcapsular hematoma
• This lesion occurs when the parenchyma of the
  liver disrupted by blunt trauma, but Glisson's
  capsule remains intact.
• The hematoma may be recognized either at the
  time of the surgery or preoperatively if a CT
  scan is performed.

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• Subcapsular hematomas
• ? involving less than 50 of the surface of the
  liver
• ?that are not expanding or
• ?ruptured
• should be left alone orpacked if discovered on
  exploratory laparotomy.

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the subcapsular hematoma

• Hematomas that are expanding during an operation
  may require exploration.
• These lesions are often caused by uncontrolled
  arterial hemorrhage, and packing alone may not be
  successful.

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• An alternative strategy would be to pack the
  liver close to the abdomen to control venous
  hemorrhage and to transport the patient to the
  angiographic suite for hepatic arteriography and
  embolization of the bleeding vessel.
• Ruptured hematomas require exploration and
  selective ligation, with or without packing.

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• ? Resectional debridement is indicated for the
  removal of peripheral portions of nonviable
  hepatic parenchyma.
• The mass of tissue removed should rarely exceed
  25 of the liver.
• ? anatomic lobectomy

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• Drain are not necessarily for minor laceration.
• They should be used
• if bile is seen oozing from the liver and in most
  patient with deep central injuries.

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• The complications following significant
• hepatic trauma
• ?Hemorrhage
• ?Infections
• ?Bilomas
• ? Biliary fistulas
• ?arterialpseudoaneurysms
• ?Biliovenous fistulas

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Non operative treatment

• The classic criteria
• ? hemodynamic stability
• ?Normal mental status
• ?Absence of a clear indication for
  laparatomyperitoneal sign
• ?Low grade liver injury
• ? Transfusion requirment of less than 2
  units

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Gallbladder and Extrahepatic Bile Ducts

• Injuries of the gallbladder are treated by
  lateral suture or cholecystectomy.
• ? T tube
• ?lateral suture
• ? a Roux-en- Y choledochojejunostomy
• ? Injuries of the hepatic ducts are almost
  impossible to satisfactorily repair under
  emergency circumstances.

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Spleen

• Splenic injuries are treated nonoperatively,
• by splenic repair(splenorrhaphy), partial
  splenectomy,
• or resection,
• depending on the extent of the injury and the
  condition of the patient.

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• History of blow,fall or sport injury to the left
  chest,flank,left upper abdomen is usually
  associated with splenic injury.
• The diagnosis is confirm by abdominal CT in the
  hemodynamically stable patients or during
  exploratory laparatomy in the unstable patient
  with a positive DPL.

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• Hemodynamically stable patient undergo US.
• If US show free fluid patient remain stable CT
  is obtaine to
• identify the source of bleeding , evaluate for
  contrast agent extravasation,other abdominal
  injury,grade and severity of the splenic injury.

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• Contrast blush is indicative of persistent
  bleeding.
• Some authors argue
• contrast blushlaparatomy
• Others argue angiographic embolization.
• Controversial

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• The classic criteria for non operative
  management
• ? Hemodynamic stability
• ? Negative abdominal examination
• ? Absence of contrast extravasation on CT
• ? Absence of other clear indication for
  exploratory laparatomy or associated injuries
  requiring a surgical intervention
• ? Absence of associated health condition that
  carry an increased risk of bleeding
  (coagulopathy,hepatic failure,use of anti
  coagulant,specific coagulation factor deficiency)
  
• ? Grade 1-3 injury

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Management

• ?Admitt to ICU
• ?Bed rest
• ?NG tube
• ?Serial abdominal examination
• ?Serial Hct
• After 48-72h reffer to intermediate care
  unit,start walking

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• If falling Hct,hypotension,persistent ileus,
  repeat CT
• IF Extravasation,pseudoaneurysm ,angiography
  embolization.
• Before discharge CT don,t need.
• Avoid intense physical activity for 3 m.

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Management

• During laparatomy
• ? Topical hemostatic agent
• ?Horizontal mattress suture
• ? Segmental or partial splenic resection
• ?Splenectomy
• ?autotransplantation