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Fatin Amirah Kamaruddin

ABDOMINAL TRAUMA

OVERVIEW
Unrecognized Closed space Blunt or penetrating Multisystem/multiple organs Need investigations but based on pts haemodynamic Resuscitation by teamworks

ANATOMY

Anterior abdomen - Anterior costal margins to inguinal creases, between the anterior axillary lines Intrathoracic abdomen or thoracoabdominal area - Fourth intercostal space anteriorly (nipple) and seventh intercostal space posteriorly (scapular tip) to inferior costal margins Flank - Scapular tip to iliac crest, between anterior and posterior axillary lines Back - Scapular tip to iliac crest, between posterior and axillary line

This anatomic classification is important in guiding the clinicians suspicion for specific organ injury.

INTRAPERITONEAL STRUCTURES
Spleen Liver Stomach Ileum Jejunum Transverse colon

RETROPERITONEAL STRUCTURES
Duodenum Pancreas Kidneys Ureters Bladder Ascending & descending colon Major abd. vessels rectum

TYPE OF TRAUMA
Blunt Direct impact or movement of organs Compressive, stretching or shearing forces Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Penetrating caused by sharp or high velocity objects that create an opening between the peritoneal cavity and the outside of the body -Small bowel (50%) -Colon (40%) -Liver (30%) -Abd. vascular (25%)

Individual Organ Injury

HOLLOW AND SOLID ORGANS


The type of injury will depend on whether the organ injured is solid or hollow.

hollow organs include:


solid organs include:


stomach intestines gallbladder bladder

liver spleen kidneys

Hollow organ when hollow organs rupture, their highly irritating and infectious contents spill into the peritoneal cavity, producing a painful inflammatory reaction called peritonitis

Solid organ damage to solid organs such as the liver can cause severe internal bleeding blood in the peritoneal cavity causes peritonitis when patients injure solid organs, the symptoms of shock may overshadow those from peritonitis

LIVER
Mostly because of blunt trauma Compressed between the force & rib cage or vertebral column Penetrating trauma relatively common:related to the size of the liver in the abd. cavity Mx: CVS statuseither operative or non-operative approach Ensure rx of coagulopathy & hypovolemia (blood pro. often req) Surgery is required only in: -the presence of other organ injury -increasing instability/ failure of non-operative mngment -usually for Grade IV and above Management: push, Pringle, plug, pack Angiography/embolisation if arterial bleeding

LIVER LACERATIONS
Grade I II Injury type/Description Hematoma: subcapsular, non-expanding, <10% surface area. Laceration: capsular tear, non-bleeding, <1cm parenchymal depth Hematoma: subcapsular, non-expanding, 10-50% SA, intraparenchymal, nonexpanding <10cm in diam. Laceration: capsular tear, active bleeding, 1-3cm parenchymal depth, <10cm in length. Hematoma: subcapsular, >50% surface area or expanding, ruptured subcapsular haematoma with active bleeding, intraparenchymal hematoma > 10cm or expanding. Laceration: >3cm parenchymal depth Hematoma: ruptured intraparenchymal hematoma with active bleeding. Laceration: parenchymal disruption of 25-75% of 1 hepatic lobe or 1-3 Couinaud segments in 1 lobe.

III

IV

Laceration: parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud segments in 1 lobe. Vascular: juxtahepatic venous injuries (central major hepatic veins, retrohepatic vena cava.)
Vascular: hepatic avulsion.

VI

SPLEEN
More in blunt trauma, often injured by direct energy applied to the overlying ribs (9th 11th ribs) Extremely thin capsule & highly vascularsusceptible to injury and bleeds profusely into peritoneal cavity LUQ pain, tenderness or guarding common Left shoulder tip/scapular referred pain (Kehrs sign) Mx: Fluid resuscitation 20% req blood In children, mostly can be managed non-operatively Surgery Grade III and above Adults, presence of other injury, physiological instability, coagulopatieslaparotomy & splenorrhaphy should be considered If splenectomy Hib, Pneumococcal & meningococcal influenza vacs, early ABx for febrile illness, prophylactic penicillin (children yes, adults controversial).

SPLENIC LACERATIONS
Grade I Injury Type/Description Hematoma: subcapsular, non-expanding, <10% surface area. Laceration: capsular tear, non-bleeding, <1cm parenchymal depth. Hematoma: subcapsular, non-expanding, 10-50% SA, intraparenchymal, non-expanding <5cm in diam. Laceration: capsular tear, active bleeding, 1-3cm parenchymal depth, not involving trabecular vessel. Hematoma: subcapsular, >50% surface area or expanding, ruptured subcapsular haematoma with active bleeding, intraparenchymal hematoma >5cm or expanding. Laceration: >3cm parenchymal depth or involving trabecular vessel. Hematoma: ruptured intraparenchymal hematoma with active bleeding. Laceration: involving segmental or hilar vessels with major (>25%) splenic devascularization. Laceration: completely shattered spleen. Vascular: hilar vascular injury that devascularizes spleen.

II

III

IV

Pancreas Retroperitoneal organ, difficult to diagnose Amylase estimation only relatively helpful Blunt:treated with conservative mx & closed suction drainage Penetrating: ERCP+surgical repair Stomach > caused by penetrating trauma Blood may be present and is diagnostic if found in NGT Surgical repair Colon If, little contamination & viability is satisfactory:repaired primarily Extensive contamination, physiologically unstable,doubtful viability: closed off/ a subsequent defunctioning colostomy formed

Duodenum Frequently associated with injuries to the adjoining pancreas Retroperitoneal, hidden injuries Sign may be gas in the periduodenal tissue seen at CT Small bowel Often associated with other injuries e.g. mesenteric haematoma or Chance fracture Individual loops may be trappedhigh-pressure rupture of a loop or tearing of mesentry Need urgent repair at laparotomy Can be temporarily occluded until hemorrhage control has been achieved Rectum Infrequent DRE is necessarypresence of blood

RENAL & UROLOGICAL TRACT


In stable pt, 1st choice ix is CT scanning with contrast Bladder injury - Suprapubic tenderness/rigidity -Difficulty voiding -Macroscopic haematuria (>95%) - CT cystogram or conventional cystography (400ml contrast) looking for extravasation Kidney most frequently injured urologic organ -75% blunt trauma -Generally,renal injury is managed non-operatively unless the pt is unstable -Kidney cn be angioembolised if required Microscopic haematuria: Warrants further inv if: - Penetrating trauma - Hypotensive - Child with >50RBC/hpf -Macroscopic haematuria/haem unstable/loin tenderness or rigidity: Always inv. - CT+contrast: inv of choice. IVP alternatives. US not as sensitive.

EVALUATION
Physiological cond. after initial resuscitation: Haemodinamically normal: ix can be full & treatment planned Haemodinamically stable: investigation is more limited,decide if whether pt can be managed non-operatively, whether angioembolism cn be used or whether surgery is required Haemodinamically unstable: immediate surgical correction of the bleeding is required

HEMODYNAMIC INSTABILITY SCORE

National Institute of Health, Sponsored Glue Grant Consortium 2006

DPL (Diagnostic Peritoneal Lavage) To assess the presence of blood in the abdomen Especially useful in the hypotensive, unstable pt with multiple injuries Positive if aspirated 10ml of gross blood Cell count: RBC > 100000 WBC > 500 High sensitivity & specificity Invasive & poor for retroperitoneal organ FAST (Focused Abdominal Sonar for Trauma) Assess the torso for the presence of blood, either in abdominal cavity or in the pericardium Focused on: pericardial,splenic,hepatic,pelvic Accurate for the detection of >100ml of free blood Rapid, reproducible, portable & non-invasive test It does not identify injury to hollow viscus

EVALUATION: BE SUSPICIOUS

Mechanism Vitals Symptoms Associated Injuries Elderly or co-morbidities intoxication

EVALUATION
U/S and Plain films of little use CT is the superior imaging modality Careful with contrast (nephropathy) Angiography remains the gold standard IVP/Cystoscopy less useful in the ED

MANAGEMENT
ABCDEs Fluid resuscitate To lap or not to lap? Unstable (with no other reason) Free air/peritonitis (antibiotics) Unexplained free fluid Many splenic/liver lacs managed nonoperatively

INDICATION FOR SURGERY


Haemodynamically unstable Peritonitis Inability to examine the patient Pneumoperitoneum/diaphragmatic rupture on CXR Significant & persistent GI haemorrhage in NGT/vomitus.

MANAGEMENT OF PENETRATING ABDOMINAL TRAUMA

BLUNT ABDOMINAL TRAUMA

ABDOMINAL COMPARTMENT SYNDROME


Symptomatic organ dysfunction that results from increased intraabdominal pressure (IAP) Etiology Massive volume resuscitation is the leading cause of ACSblunt trauma

Inflammatory states with capillary leak, fluid sequestration, inadequate tissue perfusion, and lactic acidosis can develop ACS. Gastric overdistention following endoscopy has resulted in ACS.

PATHOPHYSIOLOGY

The IAP is usually 0 mmHg during spontaneous respiration, and is slightly positive in the patient on mechanical ventilation. Increasing intra-abdominal pressure causes progressive hypoperfusion and ischemia of the intestines and other peritoneal and retroperitoneal structures release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate.
These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome. The consequences of abdominal compartment syndrome are profound and affect many vital body systems.

Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall compliance and can be protective .

ABDOMINAL COMPARTMENT SYNDROME


CLINICAL MANIFESTATIONS
CENTRAL NERVOUS SYSTEM Intracranial pressure Cerebral perfusion pressure CARDIAC Hypovolemia Cardiac output Venous return CVP SVR PULMONARY Intrathoracic pressure Airway pressures Compliance PaO2 PaCO2 Shunt fraction GASTROINTESTINAL Celiac blood flow SMA blood flow Mucosal blood flow pH RENAL Urinary output Renal blood flow GFR HEPATIC Portal blood flow Mitochondrial function Lactate clearance ABDOMINAL WALL Compliance Rectus sheath blood flow

ABDOMINAL COMPARTMENT SYNDROME


OPERATIVE DECOMPRESSION
Vacuum-assisted temporary abdominal closure device: thin plastic sheet, a sterile towel, closed suction drains, and a large adherent operative drape. This dressing system permits increases in intra-abdominal volume, without a dramatic elevation in IAP.