Case Report

Chirurgia Generale Prof. A.L. Gaspari

a.a. 2009/2010

Case Presentation Monday, 6.00h….On the way home from a night of

bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the light @ 90 km/h...in Viale di Tor

Vergata. As usual, being drunk, the driver walks out of his car

without a scratch. (...except for scratching his head in disbelief!)

The passenger…not so lucky!

Case Presentation Monday, 6.00h….On the way home from a night of

bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the light @ 90 km/h...in Viale di Tor

Vergata. As usual, being drunk, the driver walks out of his car

without a scratch. (...except for scratching his head in disbelief!)

The passenger…not so lucky!

He’s all yours!...good luck!

Case Presentation Moday, 6.00h….On the way home from a night of

bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the light @ 90 km/h...in Viale di Tor

Vergata. As usual, being drunk, the driver walks out of his car

without a scratch. (...except for scratching his head in disbelief!)

The passenger…not so lucky!

He’s all yours!...good luck!...(TO THE PATIENT!!!!)

What to do FIRST?

What to do FIRST? ATLS!!!

What to do FIRST? ATLS!!!

PRIMARY SURVEY & RESUSCITATION: “ABCDE” rule

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PRIMARY SURVEYPRIMARY SURVEY

A :A :B :B :C :C :D :D :E :E :

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PRIMARY SURVEYPRIMARY SURVEY

A :A : Airway with cervical spine protect.B :B :C :C :D :D :E :E :

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PRIMARY SURVEYPRIMARY SURVEY

A :A : Airway with cervical spine protect.B :B : BreathingC :C :D :D :E :E :

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PRIMARY SURVEYPRIMARY SURVEY

A :A : Airway with cervical spine protect.B :B : BreathingC : C : Circulation --control external bleeding.D :D :E :E :

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PRIMARY SURVEYPRIMARY SURVEY

A :A : Airway with cervical spine protect.B :B : BreathingC : C : Circulation --control external bleeding.D :D : Disability or neurological statusE :E :

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PRIMARY SURVEYPRIMARY SURVEY

A :A : Airway with cervical spine protect.B :B : BreathingC : C : Circulation --control external bleeding.D :D : Disability or neurological statusE :E : Exposure (undress) & EEnvironment (temp control)

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PRIMARY SURVEYPRIMARY SURVEY

If there is evident bleeding, what to do If there is evident bleeding, what to do IMMEDIATELY??? IMMEDIATELY???

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PRIMARY SURVEYPRIMARY SURVEY

If there is evident bleeding, what to do If there is evident bleeding, what to do IMMEDIATELY???IMMEDIATELY???

control bleeding by direct pressure!!!!!!

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PRIMARY SURVEYPRIMARY SURVEY

If there is evident bleeding, what to do If there is evident bleeding, what to do IMMEDIATELY???IMMEDIATELY???

control bleeding by direct pressure!!!!!!(or at least, try!….)

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ResuscitationResuscitation

Airway - definite airway if there is any doubt about the pt’s ability to maintain airway integrity.

Breathing /Ventilation/Oxygenation- every injured pt should received supplement oxygen

Circulation- control bleeding by direct pressure or operative intervention- minimum of two large caliber IV should be established- pregnancy test for all female of child bearing age.- Lactated Ringer is preferred & better if warm

Case Presentation

25 year old maleCar-accident, trauma on his left side

Left chest pain & no deformityLeft shoulder pain (!!!)

A good air entry

Case Presentation

25 year old maleCar-accident, trauma on his left side

Left chest pain & no deformityLeft shoulder pain (!!!)

A good air entry B Rt chest pain and bruising

Case Presentation

25 year old maleCar-accident, trauma on his left side

Left chest pain & no deformityLeft shoulder pain (!!!)

A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0 , EKG normal

Case Presentation

25 year old maleCar-accident, trauma on his left side

Left chest pain & no deformityLeft shoulder pain (!!!)

A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0 , EKG normal D GCS 15

Case Presentation

25 year old maleCar-accident, trauma on his left side

Left chest pain & no deformityLeft shoulder pain (!!!)

A good air entry, spO2 98% B Left chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0, Ht 46 , EKG

normal D GCS 15 E Chest and flank abrasions LEFT SIDE!!

Case Presentation

Transfer to PTV emergency department

TRIAGE ???

Case Presentation

Transfer to PTV emergency department

TRIAGE ??? Patient general condition Age Type of trauma Associated injuries

Case Presentation

Transfer to PTV emergency department

TRIAGE ??? Patient general condition Age Type of trauma Associated injuries

RED : Most critical injuryYELLOW : Less critical injuredGREEN : No life or limb threatened injuryBLACK : Death or obviously fatal injury

Case Presentation

Transfer to PTV emergency department

TRIAGE ??? Patient general condition Age Type of trauma Associated injuries

RED : Most critical injury

Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG

monitoring

Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG

monitoringevery hour or continuous monitoring !!!!!

Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG

monitoringevery hour or continuous monitoring

Ventilatory rate and Pulse-oximetry

Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG

monitoringevery hour or continuous monitoring

Ventilatory rate and Pulse-oximetry

Inspection

Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG monitoring

every hour or continuous monitoring Ventilatory rate and Pulse-oximetry Inspection

Seat belt mark Skin lacerations Previous surgery scar

PHYSICAL EXAMINATIONAbdominal Trauma

Physical examination unreliable Head trauma Spinal cord injuries Alcohol intoxication Use of illicit drugs Injuries to adjacent structure Significant amount of blood present Analgesia

Diagnostic MethodsAbdominal Trauma

Physical examination Bruises, abrasion over the abdomen Abdominal pain or tenderness Absent bowel sounds Unexplained hypotension

P/E equivocal or misleading.!!! Peritoneal sign falsely negative in 40% Peritoneal sign falsely positive in 20%

10% of all injuries are initially overlook

WHY?

Physical ExaminationAbdominal Trauma Evaluation

Auscultation

Physical ExaminationAbdominal Trauma Evaluation

Auscultation Chest ventilation Peristaltic activity

Physical ExaminationAbdominal Trauma Evaluation

Auscultation Chest ventilation Peristaltic activity

Palpation

Physical ExaminationAbdominal Trauma Evaluation

Auscultation Chest ventilation Peristaltic activity

Palpation Rebound tenderness Guarding Pelvic instability Digital pression for fractures assessment (ribs)

Physical ExaminationAbdominal Trauma Evaluation

Rectal examination (?)

Physical ExaminationAbdominal Trauma Evaluation

Rectal examination (?) Prostate Rectal tone

PVC and vascular access Abdominal Trauma Evaluation

Peripheral Venous Catheter (PVC)

PVC and vascular access Abdominal Trauma Evaluation

PVC At least two 16-18 G (large caliber) Complete blood count and chemistry

and coagulation Blood cross-matching test

(independently by Hb at presentation!)

Resuscitation Abdominal Trauma Evaluation

Fluid therapy Initial fluid therapy at least 1-2 L for

adults Warm fluids Cristalloids or Colloids ???

Tube Insertion Abdominal Trauma Evaluation

Gastric tube….yes or no?

Tube Insertion Abdominal Trauma Evaluation

Gastric tube Relieves distention (stomach in CT

scan) If drunk or other altered mental

status Decrease risk of unattended

vomiting But can also induce it , risk of aspiration

!!!

Tube Insertion Abdominal Trauma Evaluation

Gastric tube Relieves distention (stomach in CT scan) If drunk or other altered mental status Decrease risk of unattended vomiting

But can also induce it , risk of aspiration !!!

Caution: Facial fracture/basilar skull fracture….(AFTER CT!!)

Tube Insertion Abdominal Trauma Evaluation

Urinary catheter

Tube Insertion Abdominal Trauma Evaluation

Urinary catheter Monitor urinary output

Tube Insertion Abdominal Trauma Evaluation

Urinary catheter Monitor urinary output

Caution!!! Inability to void retrograde Pelvic fracture urethrogram or

US! Blood at the meatus Scrotal/Peryneal Ecchymoses High riding prostate

Secondary Survey: imaging or OR? Abdominal Trauma Evaluation

Diagnostic Peritoneal Lavage (DPL) Ultrasound Scanning Computer Tomography Laparoscopy Immediate Laparotomy

DPL contraindications

Absolute Patient needs laparotomy

Relative Multiple previous operations Pregnancy (Third trimester)

DPL

Gross blood >10 ml Red cells >100,000 /mm3White cells >500 /mm3Amylase > 175u/dlgross GI contentsbacteria on gram stain

DPL Simple Fast Economical Reliable

accuracy 97.3 - 99.1 % false positive 0.2 - 1.4 % false negative 1.2 - 1.3 %

DPL Oversensitive

Lacks specificity

Fails to investigate Complication

rate

6-25% non-therapeutic

laparotomy rate!!!!!Source AmountContinuationRetroperitoneum

1 - 1.7 %

CT scan contraindications

Absolute Patient needs laparotomy Unstable patient

CT scan

Non-invasive Reliable Accuracy 91 - 98.3

% Sensitivity 60 - 85 % Specificity

100 %Delineate specific organ injuryHaemoperitoneum > 100mlAssesses the retroperitoneum

CT scan Need for transfer to scanner Need cooperative patient Complications related to contrast Ionizing radiation Cost + Time + Personnel Usefulness in hollow viscus and

dyapragmatic injury ?

Spleen Injuries

CT scan will save 70 % of spleen Observation X 72 hr Healing over 6 weeks

OPSI (overwhelming post Splenectomy infection) < 1% of splenectomy , increase in children

Postoperative Vaccination on VIII P.O.Which vaccination? And why?

Haemophilus Meningococcus Streptococcus

FAST Focused abdominal sonography for trauma

To identify if the abdomen is the source of haemorrhage in unstable trauma patients ? - FLUID

To evaluate those with no major risk factors for abdominal trauma

FAST Focused abdominal sonography for trauma

Reliability accuracy 86 - 97 % sensitivity 88 - 91.7 % specificity 94.7 - 99 %

Can detect 70 ml fluid

FAST Focused abdominal sonography for trauma

Safe (Non-invasive) Cheap Rapid Can be performed in resuscitation

area

Can be used to follow-up injuries being managed conservatively!!!!!!!

FAST Focused abdominal sonography for trauma

Training required Inter-observer variation Pitfalls: subcutaneous emphysema & gas

distension& morbid obesity Cannot determine type of fluid Inadequate detection of visceral

perforation Accuracy improves on repeated

scanning

LPS (?)

ONLY stable patient!!!!!!! No extensive intra-abdominal adhesions Suction irrigator catheter Angled laparoscopes Experienced laparoscopic surgeonCan be used as adjunct to CT and allows direct visualisation of injury allows assessment of whether there is ongoing

bleeding

LPS

Unsuitable for unstable patients Performed in operating room Difficulty to examine retroperitoneum

Choice?

DPL

CT Scan

USS (FAST)

Unstable patient to assess for blood and need for laparotomy

Stable patient to define site of injurymay permit non-operative Tx

Unstable patientRequires experience

X-Ray (in the past or complimentary) Abdominal Trauma Evaluation

1. C-spine 2. Chest AP

High association of chest injuries and abdominal injuries

Free air?

3. Pelvis

X-Ray (in the past or complimentary) Abdominal Trauma Evaluation

4. ? Urethrography (if hematuria)Keep good urinary output!

Better evaluated with CT scan

5. Spine fracture Chance Fracture 20% small bowel injuries

Scout Rx- like Free-air?

Skull base (coronal and axial)

Skull base fractures?

Spine lesion?

Skull base (coronal and axial)

Skull base fractures?

Spine lesion?

Thorax. Contusion? Pneumothorax? Ribs’ fractures? Hemothorax? Flail chest?

Thorax bases Pleural effusion? Food in stomach? Diafragmatic

hernia? Liver injuries?

CT abdomen :…si apprezzano multiple

lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente

CT abdomen :…si apprezzano multiple

lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente

CT abdomen :…si apprezzano multiple

lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente

CT abdomen :…si apprezzano multiple

lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente

CT abdomen :…si apprezzano multiple

lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente

CT abdomen :…si apprezzano multiple

lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente

CT abdomen Pancreatic lesion? Retroperitoneum?

Pelvic CT Pelvic fractures?

Pelvic CT Douglas pouch:

free intrabdominal fluid - heamoperitoneum?

Quantification of haemoperitoneum

Bladder?

Pelvic CT Urethra?

Abdominal US (postop control)

Case Presentation

Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch

BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade II

Case Presentation

Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch

BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade IISpleen injury II grade with stable vital signs:Observation OR Laparotomy ?

Case Presentation

Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch

BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade IISpleen injury II grade with stable vital signs:Observation OR Laparotomy ?......OR Laparoscopy?

Observation

The patient were OBSERVED clinically monitoring vital signs (Pa, HR, sPO2, diuresis).

Blood count and coagulation every 2 hours

Observation

Observation The patient remained clinically

stable but with valid diuresis BUT

Rapid decrease of Hb and Ht and coagulative function impairment: Hb 16 >11.6 Ht 45 > 34 INR 1.2 > 1.5

Observation

Observation

Surgical managment Laparotomy or Laparoscopy?

Surgical managment The patient underwent a diagnostic

laparoscopy and control of haemostasis.

Intraoperative finding: 800cc hemoperitoneum 2 splenic fractures

Surgical managment Haemostasis by

Coagulation Floseal Tabotamp

Lavage Large abdominal drainage

Postoperative Regular course (no fever, no wound

infection, no pleural effusion) Feeding on II P.O. Control: Abdominal US on VII P.O.

(patient refused abdominal CT scan) Hb at discharge 13.7, no need of

transfusion Discharge at VIII P.O. No need of vaccination! (OPSI)

Postoperative Absolute rest at home for 4 weeks:

avoid sports with physical contact, trauma, efforts….

RISK OF DELAYED RUPTURE OF THE SPLEEN!!!

Blood count @ 1 week Abdominal US @ 1 month Outpatient control @ 1 week and 1

month

Abdominal US (control) si documenta modica falda di

versamento perisplenico, che si dispone sino in pelvi. La milza presenta disomogenee caratteristiche ecostrutturali, in particolar modo in corrispondenza del suo margine laterale, con presenza nel suo contesto di immagine lineariforme da riferire verosimilmente ad area di fibrosi. In considerazione del dato anamnestico, necessario stretto monitoraggio dei parametri ematochimici ed eventuale nuovo controllo TC

Traumatic splenic lesion. Surgical Treatment

Traumatic splenic lesion. Classification

Blunt InjuryAbdominal Trauma

Spleen 25% Liver 15% Hollow viscus 15%

Ileum Sigmoid

Kidney 12%

Retroperitoneal 13% Mesentery 5%

Compression Crushing Shearing Avulsion

Investigations NEED TO HAVE AN HIGH INDEX OF SUSPICION

Depends on:

-Haemodynamic stability

-Other injuries present

Urgency to treat

Likelihood of intestinal injury Includes:

-Lab studies

-FAST Focused Assessment with Sonography for Trauma

-DPL Diagnostic Peritoneal Lavage -CT scan

- LPT/LPS?

Surgical managementA significant solid orgsan injuries will not

heal spontaneously and surgical intervention is the only acceptable approach for it

Pringle 1908

Once the diagnostic of Hemoperitoneum has been made, routinely the next goal of the surgeons will be to prepare the patient for surgery as rapidly and efficiently as possible

Sclafani 1991

Surgical management (cont’d)

Isolated severe blunt injury may be managed nonoperatively with better survival and less blood products use.

Grindlinger 1998

TIP Patient selectionType of Trauma

AgeAssociated injuries

Blunt Liver Trauma Protocol1998

C on serva tivem an ag em en t

< = 4 u n its /2 4 h r > 4 u n its /2 4 h r

L ive r In ju ryC lass 1 & 2

O R

L iver In ju ryC lass 3 ,4 ,5

assoc ab d . in j.

S tab leC T S can

O R

U n s tab le < 9 0L avag e

B P > = 1 0 0H R < = 1 0 0

G C S > 3

Outcome

Nonoperative Less blood mortality 15% Vs up to 63% LOS shorter

TIP decision to treat

is base on the patient stability

What’s New in Abdominal Trauma Diagnostic

Ct, U/S Laparoscopy its impact is coming

Therapeutic Nonoperative management

Spleen & liver Non operative for liver gunshot

“Damage control” laparotomy “Abdominal compartment syndrome”