Abdominal trauma. Dr.L.Bahadorzadeh. T he abdomen is frequency injured after both blunt and penetrating trauma. Approximately 25% of all trauma victims will require an abdominal exploration. P hysical examination of the abdomen is unreliable in making intra abdominal injuries.
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Approximately 25% of all trauma victims will require an abdominal exploration.
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.
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.
☺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.
☺ Intravenous pyelography
☺ Pelvic Radiography
equivocal pulmonary embolism
Unexplained shock or hypotension
Altered sensorium(closed head inj,drugs)
General anesthesia for extra abdominal procedures
Clear indication for exploratory laparatomy
Previous exploratory laparatomy
☺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
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.
Doesnot reqiure radiation
Useful in the resuscitation room or emergency department
Can be repeated
Used during initial evaluation
Lower sensitivity for free fluid <500 ml
retroperitoneal and hollow viscus injuries
Normal or unreliable physical examination
Mechanism;duodenal and pancreatic trauma
Clear indication for exploratory laparatomy
Allergy to contrast media
if contrast medium extravasation is seen in minor hepatic and splenic injury an exploratory laparatomy or more recently angiography and embolization are indicated.
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
If in doubt, it is always safer to explore the abdomen than to equivocate when the depth of penetration is uncertain.
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.
Some authorities have recommended a triple-contrast CT to detect occult retroperitoneal injuries.
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.
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.
☺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.
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)
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)
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.
For penetrating trauma, organs with the largest surface area are most prone to injury (i.e., the small bowel, liver,and colon).
Penetrating trauma is not limited by the elastic properties of the tissue, and vascular injuries are far more common.
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.
Techniques for the temporary control of hemorrhage
☺ Perihepatic packing (fig3)
☺ The Pringle maneuver (fig3)
☺ Lin liver clamp
Special techniques for controlling hemorrhage from juxtahepatic venous injuries:
☺ Hepatic vascular isolation with clamps,
☺ The atriocaval shunt (fig4)
☺ The Moore-Pilcherer balloon
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
☺ Minor lacerations may be controlled
with manual compression applied directly to the injury site.
☺ Microcrystalline collagen
☺ Topical thrombin
☺ Fibrin glue
☺ Suturing of the hepatic parenchyma
(lacerations less than 3 cm in depth)
☺ Hepatotomy with selective ligation of bleeding vessels is an important technique usually reserved for transhepatic penetrating wounds.(fig5)
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.
☺ involving less than 50% of the surface of the liver
☺that are not expanding or
should be left alone orpacked if discovered on exploratory laparotomy.
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.
Ruptured hematomas require exploration and selective ligation, with or without packing.
The mass of tissue removed should rarely exceed 25% of the liver.
☺ anatomic lobectomy
They should be used
if bile is seen oozing from the liver and in most patient with deep central injuries.
hepatic trauma ;
☺ Biliary fistulas
The classic criteria
☺ hemodynamic stability
☺Normal mental status
☺Absence of a clear indication for laparatomy;peritoneal sign
☺Low grade liver injury
☺ Transfusion requirment of less than 2 units
Injuries of the gallbladder are treated by lateral suture or cholecystectomy.
☺ T tube
☺ a Roux-en- Y choledochojejunostomy
☺ Injuries of the hepatic ducts are almost impossible to satisfactorily repair under emergency circumstances.
Splenic injuries are treated nonoperatively,
by splenic repair(splenorrhaphy), partial splenectomy,
depending on the extent of the injury and the condition of the patient.
The diagnosis is confirm by abdominal CT in the hemodynamically stable patients or during exploratory laparatomy in the unstable patient with a positive DPL.
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.
Some authors argue
Others argue angiographic embolization.
☺ 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
☺Admitt to ICU
☺Serial abdominal examination
After 48-72h reffer to intermediate care unit,start walking
IF Extravasation,pseudoaneurysm ,angiography embolization.
Before discharge CT don,t need.
Avoid intense physical activity for 3 m.
☺ Topical hemostatic agent
☺Horizontal mattress suture
☺ Segmental or partial splenic resection