Case Report – History of Fall and Admitted with shock

S.Gobishangar

05/09/2009

Case ReportA 53-year-old well-built man slipped on the

floor and landed on his backHe continued to suffer from sharp abdominal

pains gradually increasing in severity for the following few days

The pain was localized in the epigastrium, left hypochondrium and the back.

As he didn’t bother about his fall, his local doctor attributed these pains to gastritis.

Fourth day following his trauma, he presented to the Casualty Unit with shock and abdominal pain

He could not give relevant history as his level of consciousness continued to deteriorate.

None of his family members who were accompanying him knew about his trauma.

On ExaminationSBP 50-60 mmHgHR 130 bpm. Inspection showed an abdominal mass.Abdominal wall was tender and rigid The mass was fixed and not pulsating

Intensive resuscitation measures started immediately

Blood was taken for cross match and investigationsThe decision of exploration laparotomy was made. The patient was temporary resuscitated, and on the

way to the operating room, he had a rapid CT examination (without contrast)

It was difficult to maintain his vital signs that started to deteriorate again; so he was rushed to theatre.

The CT scan showed a huge multi-locular abdominal cyst with blood-dense fluid inside

The origin of the cyst was not clear due to its sizeCertainly, the possibility of a leaking aortic aneurysm

was excluded. There was no other abnormal finding

At the laparotomy, A huge dark blue cyst was filling most of the

abdominal cavity and pushing the entire bowel to a small compartment

Opening the cyst revealed dark blood clots and altered blood

The cyst was multi-locular as shown on the CT The blood clots were removed and the loculi were

traced down to the retroperitoneal spaceThe retroperitoneal space was full of blood clots of

unidentified origin There was no active bleeding.

The patient by this time received 15 units of blood and 12 units of FFP

The cyst pseudo-wall, which actually was derived from the retroperitoneal wall, was closed by continuous vicryl suture to tamponade the remaining hematoma.

The patient was transferred to the ICUHe stayed there for 3 days and was

transferred to the wardHe was discharged 10 days after his

laparotomy

One month later, a follow-up CT scan showed re-accumulation of some blood clots and mild left hydroureter and hydronephrosis.

The patient was asymptomatic, but to avoid further pressure on his left kidney, he underwent an elective laparotomy.

A smaller multi-locular blood cyst was identified, opened and evacuated and the cyst wall was left open for drainage

The abdomen was closed with two drains inside

The patient went home on the 5th postoperative day

Six months follow up by abdominal ultrasound revealed no back pressure on the left kidney and absence of abdominal cysts or masses

Management of Traumatic Retroperitoneal Bleeding

Types of Retroperitoneal BleedingSpontaneousIotrogenicTraumatic

Blunt traumaPenetrating Trauma

AetiologyCentral retroperitoneum

Avulsion of Small branches from Aorta, IVCSuperior mesenteric arteryPortal vein

Lateal retroperitonumGU (Kidney, Adrenal glands, Ureters, Bladder)

Pelvic retroperitoneumPelvic Fracture sites, Disruption of deep pelvic

artery

Blunt InjuriesCan explain by 3 mechanisms

Rapid deceleration causes differential movement among adjacent structuresThis produces shear forces which causes tear in hollow,

solid, visceral organs and vascular pediclesIntra-abdominal contents are crushed between

anterior abdominal wall and vertebra / posterior thoracic cage

External compression forces causes sudden and dramatic increase in the intra-abdominal pressure.This produces rupture of hollow viscous organ

HistoryDetail history of injury

Mechanism of Injury, Vehicle, SpeedTime of injury

Abdominal traumaUrine colour

ExaminationGeneral examination

HydrationPale, Dyspnoic

CVSLow BP, PR, peripheral pulses

Abdominal examinationDistended abdomenBruising over the abdomenSeat belt marksPenetrating injuryGrey Turner signCullen sign

ChestFlail chest in lower ribsBowel sounds in the chest

Rectal examination BloodAny bony injuries in the pelvis

InvestigationHaematological

HbUS AbdomenCTAngiographyAssess the renal injury

IVU, CT/IVU

TreatmentInitial Primary survey and Resuscitation Urgent Blood transfusionThe non-operative or operative approach

is based on Mechanism of injury Hemodynamic status of the patient and Extent of associated injuries

Therapeutic embolization

Indication for Laparotomy

Persistent haemodynamic instability despite intensive volume replacement

RPB at upper central area after penetrating trauma implies damage to great vessels – Always require urgent exploration

After blunt traumaRetroperitoneal hematomas in the lateral

perirenal and pelvic areas do not require operation and should not be opened if discovered at operation.

Midline, lateral paraduodenal, lateral pericolonic not associated with pelvic, and portal hematomas are opened

Retrohepatic hematomas without obvious active hemorrhage are not opened.

After penetrating trauma

Most retroperitoneal hematomas are opened. Exceptions include isolated lateral perirenal

hematomas & lateral pericolonic haematomasRetrohepatic haematomas without obvious

active hemorrhage are not opened

Bladder InjuryExtra-peritoneal rupture of the bladder

may be managed non-operatively, intra-peritoneal rupture mandates laparotomy.

Damage control surgeryPatients with hemorrhagic or traumatic

shock who have preoperative or develop intra-operative severe metabolic derangements which will adversely affect survival

Stages of “Damage Control” Surgery

1. Limited operation for control of hemorrhage and contamination

2. Resuscitation in the SICU

3. Reoperation

Retroperitoneal Haematoma

Expanding

On Table IVP to assess Contralateral

Kidney

Explore

Not Expanding

Penetrating Trauma

On Table IVP

Explore

Blunt Trauma

Don’t Explore

Investigate Post OP

Follow upRetroperitoneal bleeding patients need

follow upUSS / CT

May need re-evacuation of Haematoma

THANK YOU