Abd Trauma - Cindy Kin (2)
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Abdominal TraumaAbdominal Trauma
Cindy Kin
Trauma Conference8 January 2007
Stanford General Surgery
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Blunt Abdominal TraumaBlunt Abdominal Trauma
Mechanisms• Direct impact• Acceleration-deceleration forces• Shearing forces
• No correlation between size of contact area and resultant injuries.
• Abdomen = potential site of major blood loss.
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Initial Evaluation and TreatmentInitial Evaluation and Treatment
Is there a surgical intraabdominal injury?
PE: guarding, peritoneal signs, tenderness, nausea. DRE.Lower rib fxs: 10-20% a/w spleen/liver injury Seatbelt sign a/w intestinal injury and mesenteric tears. Direct blunt trauma: rupture/tear of solid organs.Flank pain or contusion often late signs of retroperitoneal bleed
Rapid resuscitationCXR, Pelvic X-rayFAST v DPL v CTLabs: Hct, WBC, amylase, UA, ABG, T+C
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Blunt Abdominal TraumaBlunt Abdominal Trauma
INDICATIONS for CT• Blunt trauma with closed head injury• Blunt trauma with spinal cord injury• Gross hematuria• Pelvic fx, +/- suspected bleeding• Pt requiring serial exams, but will be lost to PE for prolonged
period (ie orthopedic procedures, general anesthesia)• Pts with dulled or altered sensorium
CONTRAINDICATIONS: unstable patients
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Blunt Abdominal TraumaBlunt Abdominal Trauma
CT FAST DPL
Accuracy 96% 95-99% 95%
Sensitivity 97% 90-92% 100%
Specificity 95% 88-90% 85%
Drawbacks Stable pts only
Cannot evaluate retroperitoneum. Cannot identify source of fluid.
0.5% miss intestinal perforation; cannot distinguish blood v bowel contents
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Blunt Abdominal TraumaBlunt Abdominal Trauma
Shock with expanding abdomen,pnemoperitoneum,retroperitoneal air
INDICATIONS FOR LAPAROTOMY
Imaging:CXRFAST/DPL/CT
Stable w/ peritoneal signs
Peritoneal signs, HD unstable, sepsis
+
equivocal Observe,+/- re-image
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Blunt Abdominal TraumaBlunt Abdominal Trauma
ROLE OF DIAGNOSTIC LAPAROSCOPY• Hemodynamically stable patients• Inadequate/equivocal FAST or borderline DPL
(80K-120K RBC/HPF)• Intermittent mild hypotension or persistent
tachycardia• Persistent abdominal signs/symptoms• Potential to decrease # of nontherapeutic
laparotomies
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Blunt Abdominal TraumaBlunt Abdominal Trauma
PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME ON FAST EXAM
• Hemoperitoneum score on ultrasound a better predictor of need for therapeutic laparotomy than admission blood pressure and/or base deficit.
• Hemoperitoneum characterized by measurement and distribution, scored
• Ultrasound score >=3 statistically more accurate than combination of SBP and base deficit in determining which patient will undergo a therapeutic abdominal operation
• 83% sensitivity, 87% specificity, 85% accuracy– McKenney et al, J Trauma 50:650-656, 2001
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Blunt Abdominal TraumaBlunt Abdominal Trauma
HEPATIC AND SPLENIC INJURIES• Unstable patients: mandatory laparotomy• Stable patients: selective nonoperative approach
Hepatic injury -Usually venous bleeding-Grade I-III: 94% success w/ nonop treatment-Grade IV-V: 20% amenable to nonop tx-HD stability, stable Hct, observation-Complications: delayed hemorrhage, bile
leak, biloma, intra/peri hepatic abscess. -If stable with ongoing bleeding - angiographic
embolization
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Blunt Abdominal TraumaBlunt Abdominal Trauma
SPLENIC INJURIES• Often arterial hemorrhage, therefore nonoperative
management less successful.
• Predictive factors for nonop success: – Localized trauma to flank/abdomen– Age<60– No associated trauma precluding obs– Transfusion <4u prbcs– Grade I-III
• Grade IV-V: almost invariably require operative intervention• Delayed hemorrhage (hours to weeks post-injury): 8-21%
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Blunt Abdominal TraumaBlunt Abdominal Trauma
RETROPERITONEAL HEMORRHAGE • Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx,
retroperitoneal bowel. • Minimal signs on examination; flank pain and contusion are late findings• FAST/DPL negative; CT can identify
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Blunt Abdominal TraumaBlunt Abdominal Trauma
DUODENAL AND PANCREATIC INJURY • Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitoneal
air on plain abdominal films. • DPL unreliable. • At laparotomy, central upper abdominal retroperitoneal hematoma, bile
staining, or air: mandates visualization and examination of panc/duo
• Duodenal injury: – 80% lacs (G I-III) - primary repair– 10-15% RYDJ, pyloric exclusion, Whipple
• Pancreatic injury– Late complications: time from injury to tx
• Abscess, pseudocyst, fistula.
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Blunt Abdominal TraumaBlunt Abdominal Trauma
DIAPHRAGMATIC RUPTURE• 3-5% of all abdominal injuries, L>R • May p/w few signs, need high index of suspicion
– Injury mechanism: compartment intrusion, deformity of steering wheel, need for extrication, fall from great height
– Prominence/immobility of L hemithorax– NGT in chest, bowel sounds in thorax– CXR: (50% with non-dx initial CXR):
• Obliteration of L diaphragm on CXR• Elevation/irregularity of costophrenic angle• Pleural effusion
• Confirm with GI contrast studies, dx laparoscopy • Ex-lap and repair
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Blunt Abdominal TraumaBlunt Abdominal Trauma
SMALL BOWEL INJURY
• Mechanism: rapid deceleration with compression, shearing• Often at points of fixation: Treitz, ileocecal valve, prior adhesions,
mesentery.• Chance fracture (transverse fx of lower thoracic/lumbar vertebral body)
raises index of suspicion for SB injury• Dx: DPL may be (-) for 6-8h after intestinal perforation, Clinical signs
absent until 6-12h post-injury. • Delayed perforation: due to direct injury, transmural contusion, ischemia
from mesenteric vascular injury; usually presents w/in days.
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Blunt Abdominal TraumaBlunt Abdominal Trauma
INJURY TO COLON AND RECTUM
• Mechanism: rapid deceleration with steering wheel compression• uncommon• Disruptions of colonic wall or avulsion injury of mesentery• Present with hemoperitoneum, peritonitis.
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Evaluation• Any penetrating wound
between nipples and gluteal crease = potential intra-abdominal injury.
• Stab wounds: stratify based on location
• GSW: higher potential for serious injury.
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Evaluation of Stab Wounds• Local exploration• DPL
– 5cc gross blood on aspiration– >20K RBC/mm3– >500 WBC/mm3– >175U amylase/100mL– Bacteria– Bile, Food particles
• CT– Limited ability to dx hollow organ
injury– Useful for posterior SW
• FAST
– Limited, high false negative rate
– Useful for pericardial injuries
• Diagnostic laparoscopy
– Useful for assessing peritoneal penetration, diaphragm injury
– Shorter LOS than negative laparotomy
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal
Flank
Peristernal Potential Mediastinal
Back
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flank
Peristernal Potential Mediastinal
Back
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore locally
triple contrast CT
Peristernal Potential Mediastinal
Back
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore locally
triple contrast CT
Peristernal Potential Mediastinal
Backadmit for obs
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest?Thoracoscopy,
Laparoscopy
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore locally
triple contrast CT
Peristernal Potential Mediastinal
Backadmit for obs
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest?Thoracoscopy,
Laparoscopy
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore locally
triple contrast CT
Peristernal Potential MediastinalCVP monitor, U/S
Observe >6h, repeat CXR
Backadmit for obs
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Gunshot Wounds• Usually require urgent exploration• Evaluation for peritoneal penetration v tangential GSW.
– CT, diagnostic laparoscopy– Use of DPL controversial due to high false negative rate
• Ballistics: – Civilian=lower velocity handgun missiles; military = higher velocity rifle missiles– Permanent and temporary cavities: Yaw, Bullet size and type– Shotgun:
• Short range: high-velocity and more concentrated• Distant range: multiple low-velocity projectiles, more diffuse, less severe
• Antibiotics: cefotetan or cefoxitin in ED
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATING GSW AND NEED FOR LAPAROTOMY
• 66 GSW underwent DL, 2/3 of GSW in upper torso• Peritoneal penetration ruled out in 62%• 29% had therapeutic ex-lap, 5% had non-therapeutic ex-lap,
4% had negative ex-lap• Hospital stay:
– 4.3 days - negative DL and associated injuries– 8.6 days - laparotomy– 1.1 days - negative DL and no associated injuries.
– Fabian et al, Ann Surg 1993; 217:557
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
IMPACT OF DIAGNOSTIC LAPAROSCOPY ON NEGATIVE LAPAROTOMY RATE
• Retrospective review 817 pts who underwent ex-lap for abdominal GSW over 4yr: negative ex-lap rate = 12.4%– 22% morbidity, LOS 5.1days
• Review of 85 pts with abdominal GSW evaluated with DL– Negative DL in 65%, no missed injuries, no subsequent need for ex-lap;
3% morbidity rate (one pt had urinary retention), LOS 1.4days– Positive DL in 35%, 28 of 30 underwent ex-lap, 86% therapeutic and
14% nontherapeutic (remaining 2 were observed for nonbleeding liver lacs)
– Sosa et al. J Trauma 1995;38(2):194
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Penetrating Abdominal TraumaPenetrating Abdominal Trauma
IMPACT OF DIAGNOSTIC LAPAROSCOPY ON NEGATIVE LAPAROTOMY RATE
• Prospective study of 121 patients with tangential GSW, HD stable• 65% negative DL• Of 25% positive DL, 92.8% (39) underwent ex-lap
– 82% (32) therapeutic, 15.4% (6) nontherapeutic, 2.5% (1) negative
• No false negative DLs, no delayed laparotomies• Sensitivity for peritoneal penetration 100%
– Sosa et al. J Trauma 1995;39(3):501