Abdominal injury KNH GITHAIGA 2.ppt

8/11/2019 Abdominal injury KNH GITHAIGA 2.ppt

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Abdominal Trauma

Githaiga J.W.


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Objectives

1.Evaluation of Abdominal Trauma

2.Mechanisms of Injury

3.Assessment of Unstable Patients

4.Assessment of Stable Patients

-Diagnostic tests

-Decision making


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Epidemiology

BLUNT AND PENETRATING ABDOMINAL TRAUMA AREMAJOR CAUSES OF MORBIDITY AND MORTALITY.

Combination injuries from bombs and explosive devices are onthe increase

In blunt abdominal trauma the spleen and liver are the mostcommonly injured organs and contribute to a mortality of 8.5%.

s attributable to RTA.

2/3RDS occur in males with a peak incidence in age 14 30yrs..

Penetrating injury has a higher mortality of up to 12%and

accounts for 1/3rdof all abdominal trauma. Gunshot and stab wounds account for 90% of penetrating

trauma.

Abdominal trauma more common in the urban set.

Males > females


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MECHANISMS OF INJURY

Shearing of organs and blood vessels due to

acceleration/deceleration forces.

Crush injury.

Rapture of hollow viscus due to rise in intraluminal pressure following compression.

Penetrating injury occurs directly from the

object causing the injury or from kineticenergy released by the object. This can

cause cavitation.


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Mechanism of Injury: Penetrating

Stab Low energy, lacerations

Gunshot

Kinetic energy transferCavitation, tumble Fragments


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Pattern of Injury in Blunt Abdominal Trauma

Spleen 40.6% Colorectal 3.5%

Liver 18.9% Diaphragm 3.1%

Retroperitoneum 9.3% Pancreas 1.6%

Small Bowel 7.2% Duodenum 1.4%

Kidneys 6.3% Stomach 1.3%

Bladder 5.7% Biliary Tract 1.1%

* Rosen: Emergency Medicine (1998)


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Management

Initial assessment and resuscitation.Establish that an abdominal injury exists

rather than emphasis on exact diagnosis.

Initial examination and resuscitation should

be simultaneous.

Principles of ABC should be applied ie

adequate airway,breathing and treating

hypovolumia. Rule out other injuries.

Insert wide bore IV cannula.


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Continous monitoring of BP,pulse rate ,

oxygen saturation.

Initial fluid resuscitation; rapid infusion

of 2 litres of crystalloid solution

followed by colloids if necessary.

Transient responders and non

responders for immediate laparotomy.


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Secondary survey

History of incident.

Physical examination of the exposed patient.

Examination of anterior and posterior abdomen.

Palapte for tenderness ,guarding and reboundtenderness.

Percussion and auscultation.

Rectal examination.

Perineal examination. Insert NG tube and urethral catheter.


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Assessment: History

AMPLE

Mechanism

MVC:

Speed Type of collision (frontal, lateral,

sideswipe, rear, rollover)

Vehicle intrusion into passengercompartment

Types of restraints Deployment of air bag

Patient's position in vehicle

A M P L E i l i f k


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A.M.P.L.E. - a simple mnemonic for key

information

A: allergies (e.g. penicillin or aspirin)

M: medication (e.g. a beta-blocker or warfarin)

P: previous medical history (e.g. previous

surgeryor anaesthetic mishap) L: last mealtime (i.e. drink versus major meal)

E: events surrounding the incident (e.g. fell 5metreswith immediate loss of consciousness)

Examine each body region meticulously


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A missed abdominalinjury can cause a

preventable death.

Abdominal Injury

Factors that Compromise the Exam

Alcohol and other drugs Injury to brain, spinal cord Injury to ribs, spine, pelvis

Caution


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Decision Making

Airway

Breathing

Circulation

HemodynamicallyStable

Hemodynamically

Unstable

Transient

Responder

S H O C K

How are you going to assess?


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Decision Making

Stable patient

CT Scan

Operative

Solid organ injury, hypotensive

Hollow viscus organ injury

Intraperitoneal bladder injury

Diaphragmatic injury Non-operative management

Observation

Interventional Radiology


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Options for Management

Laparotomy Hemodynamic Stability?

Diffuse Abdominal Tenderness

Yes No

Indications for Laparotomy Penetrating Trauma

Hemodynamically abnormal Peritonitis Evisceration Positive DPL, FAST, or CT Violation of peritoneum


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Options for Management

Hemodynamically stable penetrating injury

Serial Observation

Wound Exploration

DPL

CT scan +/- Contrast

Laparoscopy

Laparotomy

Ultrasound/echocardiac box

Pericardial windowcardiac box


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Investigations

In haemodynamically stable patients.

Full blood count and haematocrit.

Urea and electrolytes. FAST; Focused Abdominal Sonography

for Trauma- detects free fluid in the

peritoneal cavity. Non invasive andrapid. 88% sensitive,99% specific and

97% accurate.


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Focused Abdominal Sonography for Trauma

(FAST)

Demonstrate presence of free intraperitonealfluid

Evaluate solid organ hematomas

AdvantagesNo risk from contrast media or radiationRapid results, portability, non-invasive, ability to repeat

exams.

DisadvantagesCannot assess hollow visceral perforationOperator dependentRetroperitoneal structures are not visualized


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FAST Four View Technique:

Morrisons pouch (hepatorenal)

Douglas pouch (retropelvic)

Left upper quadrant (splenic view)

Epigastric (View pericardium)


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Diagnostic peritoneal lavage

98% sensitive in detecting intra

abdominal bleeding.

Does not detect diaphragmatic injuries.

Poor at detecting retroperitoneal bleed.

Invasive procedure.

Contraindicated in patients withprevoius surgery,pregnancy.


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Negative criteria; RBC count < 50,000/ul

( in penetrating trauma


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CT Scan

Replacing DPL.

98% sensitive in detecting intraperitoneal

bleeding.

Contrast enhanced CT Scan gives usefulanatomical and fuctional information on

organs.

Can identify organ injuries and be used todetermine which injuries can be managed

conservatively in stable patients.

Useful in grading solid organ injuries(liver

and spleen)..


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Laparoscopy

Increasingly used in assessing trauma.

Useful in determining peritoneal

penetration and identifying

diaphragmatic injuries.

Also can be used for treating certain

injuries.


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Mangement

Principles of management are;

Stop haemorrhage.

Debride devitalised tissues. Repair injured bowel by suturing or

resection.

Eliminate foreignbodies/contamination and intestinal

contents.


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Preoperative preparation

Immediate surgery once significant

injury is confirmed or in

haemodynamically unstable patients.

Broad spectrum antibiotics to cover

both aerobic and anerobic organisms.

Investigations and clinical findings

should guide management in stable

blunt injury patients.


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Management cont`d

Blunt abdominal trauma.

Initial assessment and resuscitation;

Haemodynamically stable or unstable.

Haemodynamically stable and no

peritonitis, negative DPL, negative

FAST, Negative CTScan observation

and serial examinations.


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Haemodynamically unstable;

Laparotomy.

Positive DPL Laparotomy

Intra-peritoneal fIuid seen on FAST

Laparotomy.

CT Scan findings of solid viscus ( liver

/spleen) injury - grade of injury


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Indications for Laparotomy Blunt Trauma

Hemodynamically abnormal with suspectedabdominal injury (DPL / FAST)

Free air

Diaphragmatic rupture

Peritonitis

Positive CT


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aAbdominal traumabaaado

Gun shotGunshotStab wound

Bluntabdominal

trauma

Mandatorylaparotomy

Evisceration,positive DPL,

Haemodynamic

instabilty,peritonitis

Stable ;

FAST,CTScan,DPL

Unstable

haemodynamically

LAPAROTOMY


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THANK YOU


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Spleen

Spleen is the commonest injured organ in blunt

abdominal trauma.

Fractures of the left lower ribs are associated with

spleen lacerations in 20 % of cases.

Most splenic injuries can be managed conservatively

after grading with CT Scan.


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Grade 1 SPLENIC INJURY


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Grade 3 injury


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Splenic injury


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Bowel

The small intestines takes up a large part of the

abdomen and is likely to be damaged in penetrating

injury.

The bowel may be perforated.Gas within the

abdominal cavity seen on plain abdominal X-Ray orCT is diagnostic.

Bowel injury may be associated with complications

such as infection, abscess, bowel obstruction, and

the formation of a fistula. Bowel perforation requires surgery.


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Perforated viscus


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Stab wound with evisceration


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Management

Splenic and liver injuries grade 1,2 and

3 may be treated conservatively.

Grade IV and V Laparotomy.

Evisceration -laparotomy


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Thank you

Abdominal injury KNH GITHAIGA 2.ppt

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