BLUNT TRAUMA ABDOMEN

• INRTODUCTION• MECHANISM N PATTERN OF INJURY• DIAGNOSTIC APPROACH• TRAUMA MANAGEMENT• DCS N ABDOMINAL EXPLORATION• DEFINITIVE ORGAN INJURY N MANAGEMENT

INTRODUCTION• Greek word 'tpavua', trauma= injury

• injury (in + jus, 'not right') or wound

• structural alteration and/or physiologic imbalance

• most common cause of death for all individuals between the ages of 1 and 44 years

• third most common cause of death regardless of age

Common causes Blunt Trauma Abd.

• Motor vehicle crash, • Fall, • Assault,• Crush• Recreational accidents

– blunt trauma is associated with multiple widely distributed injuries

Mechanism of Blunt Trauma

• Result from the impact force and deformation related to deceleration and compression

• Impact force = magnitude and duration• Deformation = strain

• Strain– Compressive/ crushing:– Shearing /opposing:– Tensile /stretching

• Strain > elasticity or viscosity = disruption/injury

Pattern of injury• Solid organ laceration

– spleen (40-55%), liver (35-45%), kidney ,pancreas

• Tear or avulsion of mesentery /pedicle of solid organ 5%

• Rupture of small bowel or colon 5-10%

• GU injuries

• Vascular injury

• Fracture of Pelvis / Ribs n vertebrae

• Diaphragmatic rupture

• Abrasion/ laceration

DIAGNOSIS

• HISTORY• CLINICAL EXAMINATION• DIAGNOSTIC SURGICAL PROCDURE• INVESTIGATION

HISTORY• Mechanism of blunt trauma• Time and place of injury• Magnitude of force/Speed of Vehicle• Status of other vehicle occupant• Patient’s position in vehicle• Duration of entrapment• Use of protective gears/ safety devices• Presence of alcohol or drug uses• Presence of psychiatric illness

PRESENTATION

• H/O trauma• Pain abdomen• Abdominal distension• Vomiting• Haematuria/ urinary retention• Loss of conciousness• Abdominal wall injury• Other associated injuries – # dislocation,

EXAMINATION

• General Physical Examination

• Systematic Abdominal examination– Abrasions, ecchymosis, seat belt abrasions or

contusion ,distension– Generalized tenderness, rebound tenderness, guarding ,

rigidity,# ribs– tympany in gastric dilatation or free air; dullness with

hemoperitoneum– Bowel sound/ bowel sound in thorax

• DRE– evaluate sphincter tone and to look for blood, perforation, or

a high-riding prostate

• Grey-Turner sign:Bluish discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.

• Cullen sign:Bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage.

• Kehr sign:L shoulder pain while supine; caused by diaphragmatic irritation (splenic injury, free air, intra-abd bleeding)

• Balance sign:Dull percussion in LUQ. Sign of splenic injury; blood accumulating in subcapsular or extracapsular spleen.

• Seatbelt sign:results from compression from an improperly positioned (too high, over the abdomen instead of the bony pelvis) lap seatbelt in a motor-vehicle crash

SEAT BELT SYNDROME

• first described by Chance in 1948 • resulting from hyperflexion of the spine about a fixed axis

anterior to the vertebral column. It includes

– # posterior process and/or the body of the lumbar spine,– fractures of the neck of the pancreas and – avulsions of the small-bowel mesentery

• Many trauma surgeons consider a true seatbelt sign as an

indication for operation, as it is associated with such a high incidence of visceral injury.

PROBLEM IN EVALUATING

• altered sensorium (injury to the brain, ingestion of alcohol or illicit drugs);

• altered sensation (injury to the spinal cord);

• injuries to adjacent structures (ribs, pelvis, thoracolumbar spine); or

• physical examination is equivocal.

INVESTIGATION

• LAB:– CBC, Coagulation profile, blood grp n cross matching,– urinalysis, urine toxicological screen, and serum or urine

pregnancy tests in females of appropriate age. – Serum amylase n lipase

• PLAIN X-RAY: CXR, pelvis; AxR– Diaphragmatic injury, pneumoperitoneum, # ribs /vertebrae

• CONTRAST X-RAY – ( IVU, RETROGRADE URETHROGRAM,

PYELOURETEROGRAM/CYSTOGRAM, VOIDING CYSTOURETHROGRAM)

• DPL• FAST• CECT• OTHERS- – ERCP/ANGIOGRAPHY

• Diagnostic Laparoscopy– no clear advantage over less invasive modalities

such as DPL or CT scan and complications can occur from trocar misplacement.

FAST

• Focused Assessment with Sonography for Trauma

• The current examination protocol consists of 4 acoustic windows with the patient supine. – pericardiac, perihepatic, perisplenic, and pelvic

(known as the 4 Ps).– Sensitivity 76 - 90%– Specificity 95 - 100%

FAST: Strengths and Limitations

Strengths• Rapid (~2 mins)

• Portable

• Inexpensive

• Technically simple, easy to train

• Can be performed serially

• Useful for guiding triage decisions in trauma patients

Limitations• Does not typically identify

source of bleeding,

• Requires extensive training

• Limited in detecting <250 cc

• Particularly poor at detecting bowel and mesentery damage (44% sensitivity)

• Difficult to assess retroperitoneum

• Limited by habitus in obese patients

Diagnostic Peritoneal Lavage

• unstable trauma patients in whom FAST results are negative or inconclusive

• 98% sensitive 96 % specific for intraperitoneal bleeding

• Open or closed

• usually infraumbilical, but may be supraumbilical in pelvic frxs or advanced pregnancy.

• Rapid, inexpensive

+VE DPL

• Free aspiration of blood , GI content, bile > 10 ml, considered +ve

• If gross blood (> 10 mL) or GI contents not aspirated, perform lavage with 1000 mL warmed NS. Allow to mix, compress abdomen and logross paient, the sent to lab. + test:

– >100,000 RBC/mm3, – >500 WBC/mm3, – >19 iu/l Amylase– >2 iu/l ALP– >0.01 mg/dl Bilirubin– Gram stain with bacteria.

• Only approximately 30 mL of blood is needed in the peritoneum

CT-SCAN

– Hemodynamically stable patients with positive FAST

– equivocal findings on physical examination,

– associated neurologic injury, or

– Significant pelvic fractures

– multiple extra-abdominal injuries.

– Inconclusive FAST with• Persistent LUQ tenderness• Gross haematuria• Hct < 33 in adult n < 35 in paeds

+ VE findings in CT

• Contrast extravasation

• Intrabdominal Hge

• Presence of pseudoaneurysm

• Thickened bowel wall

• Streaking in the mesentry

• Free fluid without assoc solid organ injury

• Free intraperitoneal air

CT is superior

• Source of bleeding• Amount of blood in abd• Precision of organ injury• Verterbral / pelvic #

• “Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be performed during resuscitation.

MANAGEMENT

• ATLS protocol Pre hospital triage

Primary survey

Resuscitation

secondary survey

Diagnostic evaluation

Definitive care

PHROPHYLACTIC MEASURES

• Antibiotics• Tetanus prophylaxis• Prevention of Venous thromboembolism n

assoc. complications– Multiple # of pelvis n lower extrimites– Ligation of large vein– Coma or spinal injury– Morbidly obese n age > 55 yrs

• Prevention of hypothermia

Maneuvers to prevent or reverse hypothermia • Warm trauma resuscitation room

• Increase operating room temperature > 85°F

• Cover patient's head with a turban or warming device

• Cover body parts not being examined or out of the operative field

• Warm IV fluid and blood n blood products

• Irrigate nasogastric and thoracostomy tubes with warm saline during laparotomy

• Irrigate open body cavity pericardial cavity, pleural cavities, and peritoneal cavity during simultaneous sternotomy or thoracotomy and laparotomy

• Turn up heating cascade on anesthesia machine

• Arteriovenous rewarming for severe hypothermia

Transfusion Practices

• Target– Hb % > 7 or 10 in acute phase of resuscitation– INR > 1.5– PPT > 45 secs– Platelet cout > 50,000 to 1 lakh /ul– Fibrinogen level > 100 mg/dl

• Components– Whole blood– PRBC– FFP– Cryopercipitate

Denver Health Medical Center's

MASSIVE TRANSFUSION PROTOCALTrigger: uncontrolled Hge, anticipated coagulopathy, SBP<90 despite 3.5 L crystalloid

• Surgery n Anesth response– Continued Rx of shock– Hge control– Correct hypothermia– Correct acidosis– Normalise Ca– Check labs q30m as

needed– Consider Recombinant

Factor VIIa therapy

• Blood Bank Response

Shipment PRBC FFP Plat Cryo

1 4 2

2 4 2 1 10

3 4 2

4 4 2 1 10

*BLOODY VISCIOUS CYCLE*Life threatening trauma

Blood Loss

Iatrogenic factors

Cellular shock

Tissue injury

Massive RBC transfusion

Preexisting disease

Progressive systemic coagulotpathy

Core hypothermia

Metabolic acidosis

Acute endogenous coagulopathy

Clotting factors deficiency

DAMAGE CONTROL SURGERY

• The purpose is to limit operative time so the physiological restoration is possible

• The objective is– Control surgical bleeding– Limit GI spillage

• Using temporary measures

ER OR ICU OR ICU

Intraoperative indications to perform ‘DCS’

Factor Level

Initial body temperature < 35°C 2.

Initial acid-base status · – Arterial pH <7.2 · – Base deficit < –15 mmol/l for < 55

< –6 mmol/l for > 55

– Serum lactate > 5 mmol/l 3.

Onset of coagulopathy – PT and /or PTT > 50 % of normal

Three phases of 'damage control' Surgery

1.Limited operation for control of hemorrhage and contamination ·

• Ctrl He/ Resection, repair / Packing/ Alternate closure or coverage

2. Resuscitation in the SICU · • Rewarm / Restore loss/ correct/ support / monitor ACS

3. Reoperation · 12 – 24 hr• Completion of definitive repairs / search for injuries / formal

closure

Bowel Injuries– Complete transection of bowel of segmental damage with GI stapler– Whip stitch 2-0 prolene for small injuries– Open end ligated using umbilical tape

Vascular Injuries– Interposition PTEE graft for Aortic injuries– Celiac artery can be ligated– SMA must maintain flow - insertion of intravascular shunt– Ligation of venous injuries except for supra renal IVC and Popliteal vein

Solid organs– Excision rather than repair– Packing and compression tamponade

Abdomen closed temporarily ( TOWEL CLIPS/ DRAPE)

ABDOMINAL COMPARTMENT SYNDROME• It is intraabdominal hypertension due to

– Intra-abdominal injury ( primary)

– splanchnic reperfusion after massive resuscitation (secondary)

• sources of increased IAP include gut edema, ascites, bleeding, and packs, among others

• The cause of edema is multifactorial.– Ischemia and reperfusion cause capillary leakage;/ dec

oncotic pressure/ venous or lymphatic obstrucion

Recommended Treatment for Abdominal Compartment Syndrome Grading According to Intra-

Abdominal Pressure (IAP)Grading IAP in mmHg Treatment

I 10-15 Normal

II 16–25 Volume expansion; mayneed

decompression

III 26–35 monitor PO2, SaO2, urine output;

decompression likely

IV >35 Decompress in OR

Abdominal Exploration

• Incision

• Liquid and clotted blood is evacuated – id major active bleeding

• Spleen n liver palpated n packed

• Infracolic mesentry inspected

• If SBP < 70 mmhg – clamp the abdominal aorta at hiatus

• uncontrolled liver bleeding- Pringle Maneuver

• Clamp the splenic hilum

• Mobilize the spleen

Pringle Maneuver

• Source of enteric contamination identified

• Anterior and posterior stomach inspected

• Duodenal injuries evaluated with kocher maneuver

• Pancreas examined during expl of lesser sac

DIFINITIVE ORGAN INJURYN

MANAGEMENT

HEPATIC TRAUMAAmerican Association for the Surgery of Trauma Grading Scales for Solid Organ Injuries

Subcapsular Hematoma Laceration

Liver Injury Grade

Grade I <10% of surface area <1 cm in depth

Grade II 10–50% of surface area 1–3 cm

Grade III >50% of surface area or >10 cm in depth >3 cm

Grade IV 25–75% of a hepatic lobe

Grade V >75% of a hepatic lobe

Grade VI Hepatic avulsion

NON- OPERATIVE Rx

• 80 to 85 % are stable

• nonoperative management is appropriate after a contrast CT

• Patients are kept at bed rest, and their vital signs are monitored in SICU

• Repeat CT at 5 to 7 days following injury to determine..

• Return to vigorous physical activity or contact sports is prohibited until a late follow-up CT shows healing.

• fails in approximately 2 to 7 per cent

OPERATIVE MANAGEMENT

Indicaiton for Opertaion

• hypotension in the field or in the emergency center,

• persistent significant tachycardia despite aggressive resuscitation,

• the presence of active hemorrhage from the liver, spleen, or kidney on the contrast CT, or

• the presence of another organ injury mandating laparotomy.

• A falling hematocrit or continuing need for transfusion during the nonoperative period

• New onset peritonitis and hypotension

General Principle

• Midline incision

• Evacuate blood n clot manually or suction device

• injured lobe is compressed between laparotomy pads

• Pringle maneuver

• Injuries of the portal triad vasculature should be addressed immediately

• Assess for retrohepatic venacava n extrahepatic venous injury---- may need sternotomy/ vascualr isolation for repair

Simple technique of haemostasis

• 60 % with 5 min of compression,

• the application of topical hemostatic agents, • Electro cautery or

• simple suture hepatorrhaphy

Advanced technique of hemostais

perihepatic packing;

extensive hepatorrhaphy;

hepatotomy with selective vascular ligation;

viable omental pack;

resectional debridement with selective vascular ligation;

absorbable mesh compression;

formal resection;

selective hepatic artery ligation;

intrahepatic balloon tamponade;

atriocaval shunt

EXTRA HEPATIC BILIARY INJURY

• Cholecystectomy• T- tube insertion– Small lacerations with no accompanying loss or

devitalization of adjacent tissue• Roux-en-Y choledochojejunostomy– all transections and any injury associated with

significant tissue loss

Complication

• Postoperative hyperpyrexia 2/3rd

• Early postoperative coagulopathies 15 %

• reoperations for persistent or late hemorrhage in 3 to 7 %.

• Self-limited biliary fistulas - 8 to 10 %

• Biliomas

• Hepatic necrosis

• Arterial pseudoaneurysm

• Intra-abdominal abscesses 4 to 10 %

SPLENIC TRAUMA

• most common • may present as – 'delayed‘ rupture• 48 Hr after initial injury (expanding subcapsular

hematoma

– or 'spontaneous' rupture • diseased spleen usually results from trivial trauma

• often associated with fractures of the left lower ribs

SPLENIC TRAUMA

Subcapsular Haematoma Laceration

Grade I <10% of surface area <1 cm in depth

Grade II 10–50% of surface area 1–3 cm

Grade III >50% of surface area or >10 cm in depth >3 cm

Grade IV >25% devascularization Hilum

Grade V Shattered spleen/ completely devascularised

American Association for the Surgery of Trauma Grading Scales for Solid Organ Injuries

NON-OPERATIVE

• Confirm extent of injury with USG, CT• 20 to 45 %• ICU care, • Bed rest is imposed• Transfer to ward 24 to 48 h of observation• restrict activity for 4 to 6 wks n contact sports 6 mth • Regular rescanning • Resolution of the trauma, at 3 months in 90 per cent• One-third 'fail' and require surgery

Conservative in Children

• overwhelming postsplenectomy infection.

• multiple injuries are also less common.

• Better capacity for haemostasis,

• Increased resilience of the cardiovascular system to hypovolaemia,

• Increased compliance of the splenic capsule and septa.

OPERATIVE

• SPLENECTOMY

• PATIAL SPLENECTOMY

– upper or lower pole injury

– Hemorrhage from the raw splenic edge is controlled with horizontal mattress sutures, with gentle compression of the parenchyma

• SPLENIC REPAIR (splenorraphy)

SPLENORRAPHY

• Aim - control of bleeding and to avoid causing or leaving behind infarcted splenic tissue.

• Simple suture of the torn spleen often results in further bleeding, but the use of a buttress technique with collagen, omentum, or Teflon pledgets can be effective.

• Haemostatic agents can be used in addition to the sutures .

• electrocautery; argon beam coagulation

• The spleen may be wrapped in the greater Omentum /Mesh to assist haemostasis,

INDICATION FOR SPLENECTOMY20-30%

– Extensive hilar injury

– Avulsion

– extensive fragmentation

– failure to achieve haemostasis following attempted splenorrhaphy

– any injury of grade II or higher in a patient with coagulopathy or multiple injuries

– Haemodynamic instability

Complication

• Postop Hge / Recurrent Bleeding• Subphrenic abscess• Pancreatic ascites or fistula• Thrombocytosis n thrombosis• Postsplenectomy infection

SPLENOSIS N AUTOTRANSPLANTAION

• Splenosis, is spontaneous regrowth of splenic tissue

• lower incidence of overwhelming postsplenectomy infection.

• may be as high as 50 per cent following trauma.

• 25 to 30 g of tissue is needed for protection

• splenic tissue can be autotransplanted at the time of surgery

• normal splenic vasculature is crucial for maximum protection.

MESENTRIC TRAUMA

• Blunt trauma to the abdomen- 5%

• The injury can result in– mesenteric hematomas – free intraperitoneal hemorrhage, or – devascularization of the bowel causing ischemia . – Compression tears the intima of the mesenteric

vessels, leading to secondary thrombosis.

• Observation

• Proximal vascular control,exploration n ligation

• Autogenous venous graft-SMA /vein with ext ishcemia

• Non-viable intestine should be resected and primary anastomosis n mesenteric defect sutured

• If bowel viability or graft patency are tenuous, the proximal bowel can be brought out as an enterostomy

STOMACH N SMALL BOWEL

• Gastric wounds can be oversewn with a running single-layer suture line or closed with a TA stapler

• Most commonly missed injury– Posterior wall thro n thro– Within mesentry of lesser curvature– High fundus

• Delineate a questionable injury,

• Partial gastrectomy may be required for destructive injuries, or Drainage procedure if vagus or nerve of laterjet injured

Small intestine injuries • Primary repair for < 1/3 of cirucmference

injury. – Transverse running 3-0 PDS

• segmental resection followed by end-to-end anastomosis– Single layer 3-0 polypropylene suture

DUODENUM

• spectrum of injuries – hematomas, – perforation – and combined pancreaticoduodenal injuries

• duodenal hematomas are managed nonoperatively with nasogastric suction and parenteral nutrition- 2 wk

• Small perforation n laceration- Primary repair using a running single-layer suture of 3-0 monofilament

• Extensive injuries of the first portion of the duodenum – débridement and end-to-end anastomosis.

• defects in the second portion of the duodenum should be patched with a vascularized jejunal graft.

• Duodenal injuries with tissue loss distal to the papilla of Vater and proximal to the superior mesenteric vessels are best treated by Roux-en-Y duodenojejunostomy

• injuries in the distal third and fourth portions of the duodenum (behind the mesenteric vessels) should be resected, and a duodenojejunostomy

Pancreatic trauma

• Classification of pancreatic injuries (Lucas 1977) Grade I • Simple superficial contusions with minimal parenchymal damage

Grade II • Deep lacerations, perforations, or transection of the tail or the body of

the pancreas with the possibility of pancreatic-duct injury

Grade III • Severe transection, perforation, or crushing injuries to the head of the

pancreas with or without ductal injury, but with an intact duodenum

Grade IV• Combined pancreaticoduodenal injuries – mild pancreatic injury or – severe damage with ductal disruption

• Grade-I injuries managed safely by drainage of the pancreatic bed

• Grade- II injuries a distal pancreatectomy, with ligation of the stump of the duct and drainage of the pancreatic bed. With or without splenectomy

Roux-en-Y pancreaticojejunostomy preserve both spleen n distal pancrease

Grade III n Grade IV injuriesRoux-en Y Choledochojejunostomy Roux-en-Y pancreaticojejunostomyPyloric exclusion operationWhipple's pancreaticoduodenectomy

Complication• Delayed hge• Pancreatic necrosis• Abdominal infection• Pancreatic fistula• Duodenal fistula• Pancreatic pseudocyst• Intrabdominal abscess

COLON INJURY

• three methods for treating colonic injuries– primary repair, • Lateral suture repair• Resection of damaged segement n reconstruction with

ileocolostomy or colocolostomy

– end colostomy, and

– primary repair with diverting ileostomy.

RECTAL INJURY• Intestinal diversion is required– Loop ileostomy– Sigmoid loop colostomy

• Repair depends on accessibility of the injury• If the rectal injury is extensive, – end colostomy (Hartmann's procedure).

• Extensive injuries may warrant presacral drainage

• APR may be necessary in some destructive injuries

Complication

• intra-abdominal abscess, -10%• fecal fistula, 1-3% • wound infection, and• stomal complications 5%– necrosis, stenosis, obstruction, and prolapse

GENITOURINARY TRAUMARENAL TRAUMA

• Blunt trauma causes 65 per cent of all renal injuries: this usually results from a direct blow

• Indirect injury due to acceleration- deceleration – Renal pedicle – 85%– Renal vein – 70%– Both – 10%

Grading of Renal Trauma by the American Association of Surgery of Trauma

Grade I: microscopic or gross hematuria, normal radiographic study or contained subcapsular hematoma without a parenchymal laceration.

Grade II: non expanding perirenal hematoma or cortical laceration < 1cm deep

Grade III: laceration > 1cm deep into the parenchyma without extravasation

Grade IV: laceration > 1 cm deep with extravasation, or segmental arterial thrombosis

Grade V: multiple major lacerations, shattered kidney or pedicle injury

• operative guidelines for GU injury :

– accurate assessment of the degree of injury; – adequate debridement of injured tissue; – meticulous hemostasis;– watertight repair of the collecting system; – adequate drainage of the renal bed – tension-free spatulated anastomosis, – and good urinary drainage with ureteral stents

and/or nephrostomy tubes

• 90% Blunt renal injuries Rx nonoperatively

• Minor (grade I and II) injuries are properly treated by observation.

• Renovascular injuries n destructive parenchymal injuries with hypotension requires operative Rx

• Parenchymal renal injuries are treated with hemostatic and reconstructive techniques

• The collecting system should be closed separately, and the renal capsule should be preserved to close over the repair of the collecting system

• For destructive parenchymal or irreparable renovascular injuries, nephrectomy may be the only option

URETERAL INJURY

• Injuries to the ureters are uncommon but may occur in patients with pelvic fractures

• methylene blue or indigo carmine iv used to delineate the site of injury.

• In DCS, the ureter can be ligated on both sides of the injury and a nephrostomy tube placed

Distal Ureteral injury– Debridement n reimplantation faciliated with a posas hitch n

/or Boari flap – transureteroureterostomy

Mid n Upper Ureter injury– The injured midureter is best repaired by primary anastomosis .

/ transureterouretrostomy

For extensive damageIleal ureter or autotransplantation of kidney

Most anastomoses after repair of ureteral injury should be stented for 3- 4 wks

UB INJURY• 75 %of bladder injuries• Fractured pelvis is the injury most commonly associated

with a ruptured bladder (at least 80 per cent).

Type of injury• extraperitoneal extravasation– Anterior wall injury

• Intrapertoneal extravasation– Posterior wall injury/ rent in dome

• Injury best diagnosed with contrast study

• Bleeding from a contused bladder usually resolves with drainage by urethral catheter.

• Most extraperitoneal ruptures of the bladder may be managed nonoperatively bladder decompression for 2 wks

• Operative repair– Heavy hematuria – massive extravasation, and, – injury to the bladder neck

• two-layer closure with absorbable suture from the inside of the bladder

Intraperitoneal rupture - Operative .

• Running single layer with 3-0 absorbable monofilament suture.

• Suprapubic cystotomy and urethral catheters in all operative Rx.

URETHRAL INJURY

Posterior (membraneous) unrethral injury

Anterior (bulbous)urethral injury

POSTERIOR INJURY

• Immediate SPC 2-3 wks– Voiding

cystourethrogram• Delayed urethra

reconstruction– Within 3 months– Cystogram/urethrogram– SPC and Foleys for 1

month

ANTERIOR INJURY

• Urethral contusion:– Observation

• Laceration– SPC

• Laceration with extravasation– Drainage n SPC

• Repair

complications• Haemorrhage• Urinoma• Hydronephrosis• Renal hypertension• Calculus formation• Pyelonephritis• AV fistula• stircture• Pelvic abscess• Urinary incontinence

VASCULAR INJURY

• blunt trauma most commonly involves renal vasculature and rarely the abdominal aorta.

• Blunt avulsions of the SMA are rare but should be considered in patients with a seat belt sign

• blunt injuries are typically intimal tears of the infrarenal aorta and are readily exposed via a direct approach.

• Heparinized saline (50 u/l) is injected

• To avoid future vascular-enteric fistulas, the vascular suture lines should be covered with omentum

• Arterial repair should always be done for the aorta ,superior mesenteric, proper hepatic, renal, iliac, femoral, and popliteal arteries.

• Venous repair should be attempted for injuries of the superior vena cava, the inferior vena cava proximal to the renal veins, and the portal vein, although the portal vein may be ligated in extreme cases.

• Follow-up imaging is performed 1 to 2 weeks after injury to confirm healing.

Options for the Treatment of Vascular Injuries

• Observation / Digital compression• Ligation • Lateral suture repair • End-to-end primary anastomosis • Interposition grafts

– Autogenous vein – Polytetrafluoroethylene graft – Dacron graft

• Transpositions • Extra-anatomic bypass • Interventional radiology • Stents • Embolization

THANK YOU…