BLUNT TRAUMA ABDOMEN

(OPERATIVE v/s CONSERVATIVE MANAGEMENT)

Dr.Anil Haripriya

INTRODUCTIONINTRODUCTION

- Motor vehicle accidents are responsible for 75% of all blunt trauma abdominal injuries

- More common in elderly due to less resilience.

- Blunt injuries causes solid organ trauma (spleen, liver and kidneys) more often than hollow viscera.

- Multi organ injury and multiple system injury are also more common in blunt injury than in other types.

CRUSHING

-Direct application of a blunt force to the abdomen

SHEARING

-Sudden decelerations apply a shearing force across organs with fixed attachments

BURSTING

-Raised intraluminal pressure by abdominal compression accurately in hollow organs can lead to rupture

PENETRATION

-Disruption of bony areas by blunt trauma may generate bony spicules that can cause secondary penetrating injury

MECHANISMS OF INJURYMECHANISMS OF INJURY

PRESENTATION

•Varies widely from haemodynamic stability with minimal abdominal signs to complete cardiovascular collapse and may change from one to the other with alarming rapidity

Whether the patient is haemodynamically

stable unstable

FIRST PRIORITIES PROTOCOL :

Brief clinical examination to evaluate ABC along with cardiovascular status with blood pressure and pulse measurement.

Accordingly, resuscitation and management of shock by

- maintenance of ABC

- IV fluids

- nasogastric tube insertion

- Catheterization

INITIAL ASSESSMENTINITIAL ASSESSMENT

SECOND PRIORITIES PROTOCOL

•Physical examination

•Base line investigations

•Four quadrant tap

•Diagnostic peritoneal lavage (DPL)

•Ultrasound – FAST (focus assessment with sonography for trauma)

•Abdominal CT scan

•Diagnostic laparoscopy

•Laparotomy

HISTORY :

- To know injury mechanism (mode of injury) –

to anticipate injury patterns and raise the index of suspicion for occult injury

- Events preceding the injury

General principles: - Serial examinations by the same examiner improves sensitivity

- Spinal cord injury masks clinical findings

- Tenderness blunted by intoxicants

HISTORY AND PHYSICAL EXAMINATIONHISTORY AND PHYSICAL EXAMINATION

General Examination : relating to hemodynamic stability

Abdominal findings:- Inspection :

for abdominal distension for contusions or abrasionslap belt ecchymosis – mesenteric, bowel, and lumbar spine injuries periumblical (Cullen sign) and flank (Grey Turner Sign) ecchymosis – retroperitoneal haematoma

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

- Palpation : for tenderness, guarding and/or rigidity, rebound tenderness – hemoperitoneum

- Percussion : Dullness/ shifting dullness – intrabdominal collection Auscultation : +/- nce of bowel sounds

PHYSICAL EXAMINATION cont.PHYSICAL EXAMINATION cont.

The classical ‘seatbelt’ sign. The bruising on the left breast is from the shoulder belt and the low bruising to the abdominal wall is from the lapbelt.

Rectal findings Check for gross blood - pelvic fracture Determine prostate position – high riding prostate –

urethral injury Assess sphincter tone – neurologic status Distal pulses- Assess for absence or asymmetryAssessment of other associated injuries i.e. multiple

fractures, spinal injuries etc.

PHYSICAL EXAMINATION PHYSICAL EXAMINATION cont..cont..

INVESTIGATIONS –

Aim

To identify To decide When

(those with injury) (which ones (how quickly

need laparotomy) this must be

undertaken)

DIAGNOSTIC STRATEGY DIAGNOSTIC STRATEGY

DIAGNOSTIC STRATEGY cont..DIAGNOSTIC STRATEGY cont..

BASIC DATA Complete haemogram with hematocrit, ABG,

Electrocardiogram- Renal function tests- Urine analysis –

+nce of hematuria – genito urinary injury -nce of hematuria – does not rule out it

- Serum amylase / lipase or liver enzymes - se -suspicion of intraabdominal injuries

Chest radiograph – Pneumothorax/hemothoraxRaised left/right hemidiaphragm –

perisplenic/hepatic hematoma.Lower ribs fracture – liver/spleen injury.Abdominal contents in the chest –

ruptured hemidiaphragm

Abdominal radiographs –-Pneumoperitoneum –perforation of hollow viscus-Ground glass appearance –

massive hemoperitoneum

DIAGNOSTIC STRATEGY DIAGNOSTIC STRATEGY cont…cont…

DIAGNOSTIC STRATEGYDIAGNOSTIC STRATEGYAbd. Radiograph cont…

- Dilated gut loops- retroperitoneal hematoma or injury

- Retroperitoneal air outlining the right kidney – duodenal injury

- Double wall sign – air inside and outside the bowel- Distortion or enlargement of outlines of viscera –

hematoma in relation to respective organs

DIAGNOSTIC STRATEGY cont…DIAGNOSTIC STRATEGY cont…Abd. Radiograph cont…

- Medial displacement of stomach – splenic hematoma

- Obliteration of Psoas shadow – retroperitoneal bleeding

- Pelvic bone fracture – bladder/urethral/rectal injury- Fracture vertebra – ureter injury / retroperitoneal

hematoma

INDICATIONS FOR FURTHER TESTING- Unexplained haemorrhagic shock - Major chest or pelvic injuries - Abdominal tenderness - Diminished pain response due to

- Intoxication - Depressed level of consciousness - Distracting pain- Paralysis

- Inability to perform serial examination

FOUR QUADRANT TAP:- Overall accuracy – about 90% - Positive tap – obtaining 0.1 ml or more of non clotting

blood - Negative tap does not rule out haemorrhage

DIAGNOSTIC PERITONEAL LAVAGE

Criteria for positive tap – - Gross bloody tap - >1,00,000 RBCs per mm- > 500 white blood cells per mm- Elevated amylase level- Presence of bile or bacteria or faeces

ULTRASOUND -FAST EXAMINATIONS (focused assessment with sonography for

trauma).Advantages- Inexpensive, noninvasive and portable - Performed by emergency physicians and surgeons trained in

performing FAST examinations.- Avoids risks associated with contrast media - Confirms presence of hemoperitoneum in minutes

- Deceases time to laparotomy- Great adjunct during multiple casualty disasters

- Serial examination can detect ongoing hemorrhage - Differentiates pulseless electrical activity from extreme

hypotension- With pregnant trauma patients, determines gestational age and

fetal viability

Disadvantages -A minimum of 70 ml of intraperitoneal fluid for positive study.Accuracy is dependent on operator / interpreter skill and is decreased

with prior abdominal surgery. Technically difficult with – obese, ileus or subcutaenous emphysema

is present Does not define exact cause of hemoperitoneum Sensitivity is low for small-bowel and pancreatic injury

Sensitivity – 69%-99%Specificity – 86%-98%

Technique -

Four basic transducer positions used to find abdominal fluid.

Subxiphoied – hemopericardium

Right upper abdominal quadrant -

fluid in Morrison’s pouch

Left upper abdominal quardant –

fluid in perisplenic space

Suprapubic –

fluid in Douglas pouch

ABDOMINAL CT SCAN-Latest generation of helical and multislice scanners provides rapid and accurate diagnostic information.

-Criterion standard for solid organ injuries.

-Help quantitate the amount of blood in the abdomen and can reveal individual organs with precision.

TABLEDiagnostic Modalities in Abdominal Trauma

 

PERITONEAL LAVAGE

ULTRASOUND CT SCAN

Use Records intra-abdominal haemorrhage in stable/unstable trauma

Reveals intra-abdominal haemorrhage in stable and unstable in patients

Reveals organ of injury and extent of blunt/penetrating abdominal trauma in stable patients

Contra-indications

Urgent demand for laparotomy Prior abdominal surgeryPregnancy and obesity

Urgent demand for laparotomy Obesity and subcutaneous emphysema

Need for emergency laparotomy in an unstable patient  Unco-operative patients Allergy to contrast material

Drawback Unreliable in retroperitoneal and diaphragmatic trauma

Failes to show small amount of fluid

Unreliable in detection of rupture of bowel and diaphragmatic injuries Time consuming  High cost

TABLEDiagnostic Modalities in Abdominal Trauma cont…..

PERI-TONEAL LAVAGE

ULTRA-SOUND

CT SCAN

Sensitivity 100% 84% 89%**

Specificity 97% 88% 98%**

Accuracy 99% 86% 97%

* Gruessner B, Mentges B, Duber C, et al : Sonography versus peritoneal lavage in blunt abdominal trauma. J Trauma 29:242, 1999.

** Meyer D M, Thal E R, Weigelt J A, et al: The role of abdominal CT in the evaluation of stab wounds to the back. J Trauma 29:1226, 1999.

LAPAROSCOPYLAPAROSCOPYAdvantages- extent of organ injuries and determines the need for

laparotomy- Defines which intraabdominal injuries may be safely

managed nonsurgically- More sensitive than DPL or CT in uncovering

- Diaphragmatic injuries- Hollow viscus injuries

- Surgery can be done in same sitting - With laparoscope with minimal trauma - Open surgery

- Sampling for HPR can be taken

Disadvantages:- pneumoperitoneum may elevate ICP - General anesthesia usually necessary- Patient must be hemodynamically stable

Complications:- bleeding or injury- Gas embolism and pneumoperitoneum

LAPAROSCOPY LAPAROSCOPY cont…cont…

LAPAROTOMYLAPAROTOMYINDICATIONS

Absolute criteria• Peritonitis (gross blood, bile or faeces)• Pneumoperitoneum or pneumoretroperitoneum• Evidence of diaphragmatic defect• Gross blood from stomach or rectum• Abdominal distension with hypotension• Positive diagnostic test for an injury requiring

operative repair

NON OPERATIVE INJURY NON OPERATIVE INJURY MANAGEMENTMANAGEMENT

General considerationscriteria for non operative management- Patient hemodynamically stable after initial

resuscitation- Continuous patient monitoring for 48 hrs- Surgical team immediately available- Adequate ICU support and transfusion services

available- Absence of peritonitis- Normal sensorium

NON OPERATIVE INJURY NON OPERATIVE INJURY MANAGEMENTMANAGEMENT

- Angioembolization may be alternative to surgical intervention

- All patients with solid organ injury managed nonoperatively require admission for observation, serial hematocrit measurement, and repeat imaging

ORGAN INJURIESORGAN INJURIESSOLID ORGANS-Solid organs most commonly injured

in blunt traumasIn decreasing incidence of injury

–Spleen, liver, kidneys, intraperitoneal small bowel, bladder, colon, diaphragm, pancreas and duodenum

HOLLOW VISCERA:- duodenum commonly injured - Small bowel injured at relatively fixed areas

(duodenojejunal flexure and ileocaecal junction) by shearing force

- Colon relatively protected. - Gaseous distension of caecum – most vulnerable

part as fixed.

- Stomach rarely injured – compression cause esophagogastric junction bursting

RETROPERITONEUM AND RETROPERITONEUM AND UROGENITAL TRACTUROGENITAL TRACT

Kidney injury - common next to spleen and liverPancreatic injury - 4% cases of traumaBladder - most commonly injured extra

peritoneally by shearing at the vesico urethral junction.

- intraperitoneally by blunt force on distended bladder

Rupture of prostatic urethra by shear forces is commonly seen with haemorrhage

CHILDHOOD TRAUMACHILDHOOD TRAUMABlunt trauma secondary to MVAs, falls or child

abuse is primarily responsible for 90% of childhood injuries.

Predominance - Solid organ abdominal injuries.Non-op. management – 90% success rate

(standard of care in solid organ injuries)Overall mortality – approx 15% or <

(if major vascular injuries excluded)Mortality from severe blunt trauma abdomen is

higher than penetrating injuries

CHILDHOOD TRAUMA CHILDHOOD TRAUMA cont…cont…General Principles -Understanding anatomic and physiologic

characteristics unique to children.Dose according to bodyweight

Resuscitation - maintenance of ABC

(golden hour) IV fluids – intraosseus (if needed)

Nasogastric tube insertion

Catheterization

Normothermia maintenance

PROTOCOL FOR BLUNT TRAUMA ABDOMEN MANAGEMENT

RECENT TECHNIQUESRECENT TECHNIQUESTRAUMA LAPAROTOMY

DAMAGE CONTROL LAPAROTOMY- Aim :

- Control of haemorrhage and limitation of contamination by rapid and temporary means

- Technique :- Abdominal packing for visceral bleeding - Vascular shunting – major vessel injury - Control of contamination – by stapling guns - Gastrointestinal perforation or pancreatic leakage – by

soft clamps or nylon ties

TEMPORARY CLOSURE OF THE ABDOMEN- Indication –- Permanent closure not possible due to need for

observation – to avoid second look surgery.- Techniques -

- By row of towel clips – quickest method of closure and re-opening

- Continuous nylon sutureWith fascia left wide open in both - Emptied and opened out intravenous fluid bag

(‘Bogata bag’) Sutured or stapled to the skin - “Opsite” covered abdominal pack

Temporary closure of the

abdomen using two Opsite sheets.

NEWER TECHNOLOGIES NEWER TECHNOLOGIES

ROBOTICS –Robot assisted surgeries

(eg. In microsurgical techniques – eliminate hand tremors)

Trainer robots -

(eg. Eagle trauma patient simulator)

INFORMATION TEHCNOLOGYEstablishment of city emergency medical system

(EMS) with personal status monitor (PSM), vehicle status monitor (VSM), global positioning satellite (GPS), and wireless local area network (LAN).

CONCLUSIONCONCLUSIONControversies regarding management

still exist b/c of varied presentation.Close supervision with sophisticated

infrastructure and quick action significantly reduces mortality.

Establishment of trauma centres with persons of different specialties working together as a team.