Management of Management of Abdominal Trauma & Abdominal Trauma &

Damage Control SurgeryDamage Control Surgery

EHSAN ULHAQ

P.G.R General Surgery

Case 1Case 1

25 years old male, coal mine worker in dara adam 25 years old male, coal mine worker in dara adam kheilkheil

Hit by trolley full of coal in left Flank areaHit by trolley full of coal in left Flank area ExaminationExamination

Well oriented, cloth stained with blood and coal Well oriented, cloth stained with blood and coal Airway: clearAirway: clear Breathing: 32 Breathing: 32 Circulation: Pale, pulse 120, BP 90/60Circulation: Pale, pulse 120, BP 90/60 Disability: No LOC, moving all four limbsDisability: No LOC, moving all four limbs

Case 1Case 1

ExaminationExposure: ExaminationExposure: large wound in the left flank and abdominal viscera large wound in the left flank and abdominal viscera

was lying outside contaminated with coal particles was lying outside contaminated with coal particles and dustand dust

Management:Management: IV fluids, analgesics, antibiotics, tetanus prophylaxisIV fluids, analgesics, antibiotics, tetanus prophylaxis NG and urinary catheters were passedNG and urinary catheters were passed Patient was shifted to OT for Emergency exploratory Patient was shifted to OT for Emergency exploratory

LaprotomyLaprotomy

Case 1Case 1

Laprotomy findingsLaprotomy findings Large wound in the left flank regionLarge wound in the left flank region All abdominal viscera contaminated with coal particles and All abdominal viscera contaminated with coal particles and

dustdust Disrupted descending colon and sigmond colonDisrupted descending colon and sigmond colon 6 cm rent in the left diaphragm6 cm rent in the left diaphragm Haemi peritonem about 600 mlHaemi peritonem about 600 ml Spleen, liver, kidney and rest of the other viscera were Spleen, liver, kidney and rest of the other viscera were

normalnormal Fracture 10 and 11 th ribFracture 10 and 11 th rib

Case 1Case 1

Surgical procedures done:Surgical procedures done: Left side chest tube was passedLeft side chest tube was passed Left hemi diaphragm repaired Left hemi diaphragm repaired Resection of disrupted descending colon and Resection of disrupted descending colon and

sigmoid colon done with sigmoid colon done with double barrel colostomydouble barrel colostomy Peritoneal wash done with 5 litres of NSPeritoneal wash done with 5 litres of NS

Post operative CoursePost operative Course

IV fluids, IV antibiotics and analgesics were givenIV fluids, IV antibiotics and analgesics were given 2 pint of blood transfused2 pint of blood transfused Base line investigation were doneBase line investigation were done X ray Chest and X ray pelvisX ray Chest and X ray pelvis Insentive spirometryInsentive spirometry Diet started on second post OP dayDiet started on second post OP day Patient ambulated on 2Patient ambulated on 2ndnd post OP day post OP day Daily wound washDaily wound wash Chest tube taken out on 3Chest tube taken out on 3rdrd day day Patient discharge on 5Patient discharge on 5thth post op day post op day

Case 2Case 2

30 years old male 30 years old male RTA ( pedestrian vs motor cycle ) 2 hoursRTA ( pedestrian vs motor cycle ) 2 hours Hit by motorcycle handle in the left hypo chondrium regionHit by motorcycle handle in the left hypo chondrium region Examination:Examination:

Well oriented, pale looking, severe pain abdomenWell oriented, pale looking, severe pain abdomen Airway: clearAirway: clear Breathing 30 /minBreathing 30 /min Circulation: pale looking, pulse feeble, BP90/40Circulation: pale looking, pulse feeble, BP90/40 Disability: No LOC, moving all four limbsDisability: No LOC, moving all four limbs

Case 2Case 2

Examination:Examination: Abdomen: tense, tenderAbdomen: tense, tender

Assessment: Blunt abdominal trauma with Assessment: Blunt abdominal trauma with haemodynamic instabilityhaemodynamic instability

Management:Management: IV line passed, IV fluids, IV analgesic, IV antibiotics IV line passed, IV fluids, IV analgesic, IV antibiotics

givengiven Urinary catheter and NG tube passedUrinary catheter and NG tube passed Patient shifted to OT for emergency exploratory Patient shifted to OT for emergency exploratory

laprotomylaprotomy

Case 2Case 2

Laprotomy findings:Laprotomy findings: Haemo peritoneum of about 2 litresHaemo peritoneum of about 2 litres Completely shattered spleenCompletely shattered spleen Kidneys, liver and all the other viscera were Kidneys, liver and all the other viscera were

normalnormal Spleenectomy doneSpleenectomy done Haemostasis securedHaemostasis secured Intra operatively 2 units of blood were transfusedIntra operatively 2 units of blood were transfused

Post Operative Course:Post Operative Course: Patient shifted to ICUPatient shifted to ICU Base line investigation were doneBase line investigation were done 2 more units of blood were transfused2 more units of blood were transfused IV antibiotics givenIV antibiotics given Ca Gluconate 1 gm ( post transfusion)Ca Gluconate 1 gm ( post transfusion) Chest x ray and x ray pelvis doneChest x ray and x ray pelvis done Shifted to ward on 2Shifted to ward on 2ndnd post OP day post OP day NG out on 2NG out on 2ndnd post op day post op day Ambulated on 2Ambulated on 2ndnd post op day post op day Encapsulated organism prophylaxis givenEncapsulated organism prophylaxis given Patient discharged on 4 th post op dayPatient discharged on 4 th post op day

TraumaTrauma

Major health concern of modern world.Major health concern of modern world.

leading cause of death in age group 14---44.leading cause of death in age group 14---44.

Puts enormous strain on the resource of the Puts enormous strain on the resource of the country.country.

Trauma Care in Pakistan, J Pak Med Assoc, Vol. 58, No. 3, March 2008

Trimodal distribution of death Trimodal distribution of death

Immediate:Immediate: death within minutes. e.g brain, brain stem death within minutes. e.g brain, brain stem injuries, CV injuries.injuries, CV injuries.

Early:Early: death within hours. e.g thoraco abdominal injuries death within hours. e.g thoraco abdominal injuries

Late: Late: death within days. e.g sepsis, multi system organ death within days. e.g sepsis, multi system organ failurefailure

Golden hour: Golden hour: trauma patient should be operated within trauma patient should be operated within first hour of presentationfirst hour of presentation

Abdominal TraumaAbdominal Trauma

Commonly injured part of the body.Commonly injured part of the body.

Physical examination is unreliable.Physical examination is unreliable.

Head and spinal injuries, drugs and alcohol further complicate Head and spinal injuries, drugs and alcohol further complicate the scenario.the scenario.

High degree of suspicion of intrabdominal injury, on the basis of High degree of suspicion of intrabdominal injury, on the basis of mechanism of injury. mechanism of injury.

25 % of abdominal trauma patient require laprotomy25 % of abdominal trauma patient require laprotomy

Aetiology of abdominal traumaAetiology of abdominal trauma

Essential surgical practice, 4th edition

Penetrating Blunt Iatrogenic

FAIStab wounds

RTABlast injuriesCrush injuries

EndoscopyExternal cardiac massagePeritoneal dialysisPTCLiver biopsy

Frequency of injury in penetrating Frequency of injury in penetrating abdominal traumaabdominal trauma

LiverLiver 37%37% Small bowelSmall bowel 26%26% Stomach Stomach 19%19% ColonColon 17%17% Major vascularMajor vascular 13%13% RetroperitoeumRetroperitoeum 10%10% Mesentry Mesentry 10%10% SpleenSpleen 10%10% DiaphragmDiaphragm 05%05%

Essential surgical practice, 4th edition

Frequency of injury in blunt Frequency of injury in blunt abdominal traumaabdominal trauma

SpleenSpleen 25%25% KidneyKidney 20%20% IntestineIntestine 15%15% Liver Liver 15%15% Retroperitoneal haematoma 13%Retroperitoneal haematoma 13% MesentryMesentry 05%05% PancreasePancrease 03%03%

Essential surgical practice, 4th edition

Diagnosis Diagnosis

History of eventHistory of event

Physical examinationPhysical examination

Diagnostic modalitiesDiagnostic modalities

The test of choice will dependent on the The test of choice will dependent on the hemodynamic stability of the patient & the hemodynamic stability of the patient & the severity of associated injuires.severity of associated injuires.

Diagnostic modalitiesDiagnostic modalities

Serial Physical Examination (PE) Serial Physical Examination (PE) Local Wound Exploration (LWE) Local Wound Exploration (LWE) Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) Ultrasound (FAST) Ultrasound (FAST) CT Scan CT Scan Laparoscopy Laparoscopy Laparotomy Laparotomy

Serial Physical ExamsSerial Physical Exams

24 hour obs24 hour obs

repeated physical exams repeated physical exams

Checking for hemodynamic Checking for hemodynamic instability or development of instability or development of peritonitisperitonitis

Local Wound ExplorationLocal Wound Exploration Extend wound. Extend wound.

Penetration of the peritonium Penetration of the peritonium is considered positive.is considered positive.

25% of anterior abdominal 25% of anterior abdominal stab wounds do not penetrate.stab wounds do not penetrate.

Only 50% that do penetrate Only 50% that do penetrate actually require surgical actually require surgical intervention.intervention.

Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage

Abdominal, Abdominal, thoracoabdominal, thoracoabdominal, back, or flank stab back, or flank stab woundswounds

Positive DPL Positive DPL means emergent means emergent surgical surgical explorationexploration

DPL ProcedureDPL Procedure

to identify hollow to identify hollow viscus injury viscus injury (stomach, small (stomach, small bowel, colon) or bowel, colon) or diaphragmatic injurydiaphragmatic injury

Introduce catheter Introduce catheter infraumbilically and infraumbilically and infuse fluid infuse fluid

When is it positive?When is it positive?

Positive Tap = Gross BloodPositive Tap = Gross Blood Anterior abdominal stab wound or tangential GSW= Anterior abdominal stab wound or tangential GSW=

100,000 RBC/mm3100,000 RBC/mm3 Back or Flank Stab Wound = 5000 RBC/mm3Back or Flank Stab Wound = 5000 RBC/mm3 Thoracoabdominal Stab Wounds = 500 RBC/mm3Thoracoabdominal Stab Wounds = 500 RBC/mm3 Tangential gun shot wounds = 5000 RBC/mm3Tangential gun shot wounds = 5000 RBC/mm3 Better for small bowel and diaphragmatic injuriesBetter for small bowel and diaphragmatic injuries Does not evaluate retroperitoneumDoes not evaluate retroperitoneum

FASTFAST

FAST ScanFAST Scan Good for identification of free fluid.Good for identification of free fluid.

Rapid and cost effective.Rapid and cost effective.

Can be perform with equal accuracy by surgeons.Can be perform with equal accuracy by surgeons.

Does not evaluate retroperitonal injury.Does not evaluate retroperitonal injury.

Abdominal CTAbdominal CT

Blunt traumaBlunt trauma

Hemodynamic stablilityHemodynamic stablility

Normal or unreliable physical examinationNormal or unreliable physical examination

Retroperitoneal organ damage duodenum, Retroperitoneal organ damage duodenum, pancreas pancreas

Diagnostic investigationsDiagnostic investigations

Stable Stable UnstableUnstable

Penetrating traumaPenetrating trauma Stab wounds: Local wound Stab wounds: Local wound exploration.exploration.Gunshot: OTGunshot: OT

OTOT

Blunt traumaBlunt trauma US fast / CT scanUS fast / CT scanDPL DPL

OT OT +/-US fast+/-US fast

Plain radiographCXR: to rule out pneumo or haemo pneumothoraxXray pelvis: to rule out pelvic #

FAST: ComparisonFAST: Comparison

Barry C. Simon. Ultrasound in Emergency Medicine. Table 7-2. Pages 158-159.

Diagnostic laproscopy Diagnostic laproscopy Improved diagnostic accuracy compared toImproved diagnostic accuracy compared to

FAST: poor specificityFAST: poor specificity DPL: poor specificity, invasive, not informative for retroperitoneal DPL: poor specificity, invasive, not informative for retroperitoneal

injuriesinjuries CT: hollow viscus injuries difficult to identifyCT: hollow viscus injuries difficult to identify

reduction of nontherapeutic laparotomy rates.reduction of nontherapeutic laparotomy rates. reduction of short and long-term morbidity.reduction of short and long-term morbidity.

↓↓ICU stay, ↓overall hospital stayICU stay, ↓overall hospital stay ↓↓risk future adhesive bowel obstructionrisk future adhesive bowel obstruction

Not available in emergency.Not available in emergency.

Exploratory laprotomyExploratory laprotomy

Peritoneal signs.Peritoneal signs. Hypotension + FAST +ve in Hypotension + FAST +ve in

blunt trauma.blunt trauma. GSW. GSW. Stab wound + hypotension.Stab wound + hypotension. Visceral injury on CT scanVisceral injury on CT scan Inability to evaluate Inability to evaluate

clinicallyclinically

General resuscitation measuresGeneral resuscitation measures

ABCDE.ABCDE. Spinal precautions.Spinal precautions. IV lines and tubes.IV lines and tubes. Consent.Consent. Arrange blood product.Arrange blood product. Rapid transport to OTRapid transport to OT

Damage control surgeryDamage control surgery

During past two decade, a new surgical During past two decade, a new surgical strategy developed to avoid high mortality in strategy developed to avoid high mortality in severe trauma patients, during operation or severe trauma patients, during operation or resuscitation.resuscitation.

Stage surgeryStage surgery

OT----ICU----OTOT----ICU----OT

The lethal triad of deathThe lethal triad of death

Damage Control SurgeryDamage Control Surgery•Part I: OT•Control of hemorrhage•Control of contamination•Intra abdominal packing •Temporary closure

•Part III: OT•Pack removal•Definitive repair

•Part II: ICU•Rewarming•Correct Coagulopathy•Maintained Hemodynamic•Ventilatory Support•Injury identification

Damage Control SurgeryDamage Control Surgery

Un planned Re-OperationUn planned Re-Operation Continued bleeding despite normalization of Continued bleeding despite normalization of

coagulation functions.coagulation functions. Abdominal compartment syndrome.Abdominal compartment syndrome.

Abdominal compartment syndromeAbdominal compartment syndrome

ACS is the result of acute increase in intra ACS is the result of acute increase in intra abdominal pressure after major surgery or DCS.abdominal pressure after major surgery or DCS.

Causes:-Causes:- Peri hepatic packing.Peri hepatic packing. Bowel edema and congestion in major traumaBowel edema and congestion in major trauma Accumulation of blood in the mesentery and/ or Accumulation of blood in the mesentery and/ or

retroperitoneal space.retroperitoneal space. Persistent intra abdominal bleeding.Persistent intra abdominal bleeding.

Complication of ACSComplication of ACS

Decrease cardiac outputDecrease cardiac output ARDSARDS Bowel gangrene and ischemiaBowel gangrene and ischemia Renal failureRenal failure Cerebral edemaCerebral edema Death Death

Diagnosis of ACSDiagnosis of ACS

Decrease urine outputDecrease urine output Elevated CVPElevated CVP IA pressure >25 cm of waterIA pressure >25 cm of water IA pressure measure through foleys in bladderIA pressure measure through foleys in bladder

Management of DCSManagement of DCS

Surgical decompressionSurgical decompression Be aware of good preparation because sudden Be aware of good preparation because sudden

decompression can cause hypotension or decompression can cause hypotension or rarely asystole and death.rarely asystole and death.

Situation in pakistanSituation in pakistan

Worse situation.Worse situation. Increasing no. of trauma patient.Increasing no. of trauma patient. A study from Karachi reported that 58% of the A study from Karachi reported that 58% of the

victims of violence died before they could victims of violence died before they could reach the hospital.reach the hospital.

Lack of pre hospital care.Lack of pre hospital care. Rescue 1122.Rescue 1122. No ATLS, BLS and ACLS certified staff.No ATLS, BLS and ACLS certified staff.

Trauma Care in Pakistan, J Pak Med Assoc, Vol. 58, No. 3, March 2008

Summary Summary

ABCDE of resuscitation.ABCDE of resuscitation. Do not rely on physical examinationDo not rely on physical examination High degree of suspicion of intra abdominal injury, on the High degree of suspicion of intra abdominal injury, on the

basis of mechanism of injurybasis of mechanism of injury Blunt Trauma + HD stableBlunt Trauma + HD stable observation observation Blunt trauma + HD unstable Blunt trauma + HD unstable laprotomy laprotomy Blunt trauma + +ve FAST Blunt trauma + +ve FAST laprotomy laprotomy GS woundGS wound laprotomy laprotomy Stab wound + HD unstableStab wound + HD unstable laprotomy. laprotomy. Stab wound + HD stableStab wound + HD stable local WE local WE

Summary Summary

Surgeons should be trained in doing FAST.Surgeons should be trained in doing FAST. DCS .DCS . Keep an eye on abdominal compartment syndrome.Keep an eye on abdominal compartment syndrome. Pre hospital care in community by training police Pre hospital care in community by training police

personal, volunteers, teachers and other local bone personal, volunteers, teachers and other local bone setters.setters.

ATLS, BLS and ACLS training of the medical and ATLS, BLS and ACLS training of the medical and para medical staff in all the hospital.para medical staff in all the hospital.