Penetrating and Blunt Abdominal Trauma
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Transcript of Penetrating and Blunt Abdominal Trauma
PENETRATING AND BLUNT ABDOMINAL TRAUMA
ABDOMEN
Divided into three areas Peritoneal space Retroperitoneal space Pelvic region
PERITONEAL SPACE
Is the space between the peritoneum and the pelvis Includes
Diaphragm Liver Spleen Stomach Transverse colon A prtion of the cavity is also covered by the bony
thorax
RETROPERITONEAL SPACE
Organs include Aorta Vena carva Pancreas Kidneys Ureters Potions of the duodenum and colon
PELVIC REGION
Organs include Rectum Bladder Uterus Iliac vessels
SOLID HOLLOW
LiverPancreasKidneysUreters
IntestinesStomachGall bladderUrinary bladder
ABDOMEN CONTAINS BOTH SOLID AND HOLLOW ORGANS
COMPICATIONS OF ABDOMINAL TRAUMA
Include: Haemorrhage Shock Sepsis peritonitis
PENETRATING TRAUMA
External appearance does not dictate extent of internal injury
Trauma depends on variables such as angle and distance of impact object (e.g. bullet).
Path can vary due impact on bony prominences• e.g. - abdominal trauma should be considered with
presentation of buttock or chest gunshot wound.
Assessment should include establishing entrance and exit wound sites, and possible organs involved
If patient is stable: Care should be taken to establish path of penetrating
object, examining entire body looking for entry and exit points. Thorough examination includes Skin folds The back The peritoneum The axillae The buttocks
After locating sites of wounds, haemodynamically stable patients can have plain x-ray films taken
Computed tomography is helpful in defining injuryGunshot wounds are generally more serious than stab
wounds95% of all gunshot wounds to the abdomen cause
serious injury Common complications of gunshot wounds are haemorrhage and
sepsisNecessary for most abdominal gunshot wounds to have
exploratory laparotomy surgeryOnly 50% of stab wounds enter the abdominal cavity
due to the way in which the weapon is held by the assailant, usually right handed therefore affecting upper left quadrant.
LIVER
Grade I and II injuries often managed non-operatively.
Serial haematocrits with CT abdomen and pelvic examinations to evaluate further
Grade III to VI usually require intervention of embolisation or surgery
Important to control liver haemorrhage
Grade 1
•Haematomas affect less than 10% surface area, sub-capsular and nonexpanding
•Lacerations non-bleeding, capsular tear less than 1 cm deep
Grade 2
•Haematomas include 10-50% sub-capsular surface, with less than 1cm intrapararenchyma haematoma
•Lacerations are actively bleeding and have capsular tear 1-3cm deep without trabecular involvement
Grade 3
•Haematomas expand to greater than 50% sub-capsular
•Actively bleeding ruptured sub-capsular haematoma
•Intrapararenchyma haematoma greater than or equal to 2 cm and expanding
Grade 4
•Ruptured parenchchyma and actively bleeding
•25%-50% hepatic lobe parenchymal disruption
Grade 5
•Greater than 50% hepatic lobe parenchymal disruption
•Vascular injury includes retrohepatic vena cava and juxtahepatic venous injuries
Grade 6
•Vascular hepatic avulsion
•Considered to be incompatible with life
LIVER INJURY SCALE
SPLEEN
Like the liver, it is a dense, solid intrathoracic abdominal organ
Protected by the lower ribs (8-12)Loses blood rapidly due to it’s vascularity60% of victims of splenic injury have left
shoulder painPrimary function is to clear blood borne
bacteria, essential to immune system
SPLENIC INJURY SCALE
Grade 1
•Haematoma are sub-capsular, less than 10% surface area
• Capsular tear, less than 1cm parenchymal depth
Grade 2
•Haematoma are subcapsular, 10-50% surface area
•Intraparenchymal les than 5cm diameter
•Lacerations are 1-3cm parenchymal depth not involving a parenchymal vessel
Grade 3
•Greater than 50% expanding sub capsular , ruptured sub-capsular haematoma with active bleeding. Intrapenchymal haematomas >= 2cm and expanding
•Lacerations greater than 3cm deep or involving trabecular vessels
Grade 4
•Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen)
Grade 5
•Completely shattered spleen
•Hilar vascular injury which devascularized spleen
GENITOURINARY TRAUMA
Also abbreviated as ‘GU trauma’Most commonly involved organ is the kidneyInjury to urinary system indicated when
haematuria is present, although 10-25% of cases with significant renal damage to dot display haematuria
In urban setting, approx 25% or penetrating injuries result in renal damage, e.g. gunshot or stab wounds
KIDNEY INJURY SCALE
Grade 1
•Contusions diagnosed with normal urologic studies with level or haematuria noted
•Sub-capsular non-expanding haematomas without parenchymal lacerations
Grade 2
•Non-expanding perirenal haematoma confined to retroperitoneum
•Laceration <1cm deep without system rupture or urinary extravasation
Grade 3
•Lacerations >1cm deep without system rupture or urinary extravasation
Grade 4
•Lacerations extending through the cortex, medulla and collecting system
•Main arterial or venous injury with contained haemorrhage
Grade 5
•Completely shattered kidney
•Avulsion of renal hilium
•Devascularised kidney
STAGES OF RENAL FAILURE
• Decreased circulation and ischemia to kidneys• Trauma victims at higher risk due to
hypovolaemia, hypotension and cardiac failure Prerenal• Kidneys being affected by physiologic events
such as antibiotics and contrast media dye, both of which are nephrotoxic
• Rabdomyolysis can be a contributing factorIntrarena
l • Obstruction in venous blood flow from the
kidney or urine flow from the collection ducts to the external urethral orifice --> decreased urinary outputPostrenal
GASTROINTESTINAL SYSTEM
Before considering a bowel injury rule out decline in: Respirations Haemodynamic status Neurologic statusAs these pose a much more dangerous risk than bowel injury
Injury to bowel can cause life threatening haemorrhage, it does not change managemnt of resuscitation of the patient
Gunshot wounds cause injury 90% of the time to the GI system, whereas stab wounds only about 50% of the time
Early accurate diagnosis of GI injuries reducdes the risk of sepsis, the most common complication
PANCREAS
Incidence of injury from penetrating trauma is much higher than from blunt force trauma
Located in close proximity to the aorta, portal vein, inferior vena cava, renal veins, left kidney, liver, duodenum and spleen.
Injury to pancreas indicates injury to other organs in the area
Most deaths from pancreatic trauma result from injury to surrounding blood vessels and haemorrhage within 48hours
PANCREATIC INJURY SCALE
Grade 1
•Hematoma - Minor contusion without duct injury
•Laceration - Superficial laceration without duct injury
Grade 2
•Haematomas are major contusions
•Lacerations without duct injury or tissue loss
Grade 3
•Injuries characterised by distal transecting laceration or parenchymal injury
Grade 4
•Injuries include proximal transecting lacerations or parenchymal injury involving the papilla
Grade 5
•Laceration is a massive disruption to the pancreatic head
GALL BLADDER
Injury is rareProtected by sheltered location and smaller
sizeCholecysystectomy usually performed for
injuries only when injuries disrupt structure or associated anatomy and vasculature