Abd Trauma Cindy Kin

7/30/2019 Abd Trauma Cindy Kin

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Abdominal Trauma

Cindy Kin

Trauma Conference

8 January 2007

Stanford General Surgery


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Blunt 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 bloodloss.


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Initial 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 resuscitation

CXR, Pelvic X-ray

FAST v DPL v CTLabs: Hct, WBC, amylase, UA, ABG, T+C


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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, generalanesthesia)

Pts with dulled or altered sensorium

CONTRAINDICATIONS: unstable patients


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CT FAST DPLAccuracy 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 vbowel contents


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Shock with

expanding abdomen,

pnemoperitoneum,

retroperitoneal air

INDICATIONS FOR LAPAROTOMY

Imaging:CXR

FAST/DPL/CT

Stable w/peritoneal signs

Peritoneal signs,

HD unstable,sepsis

+

equivocal Observe,

+/- re-image


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ROLE OF DIAGNOSTIC LAPAROSCOPY

Hemodynamically stable patients

Inadequate/equivocal FAST or borderline DPL(80K-120K RBC/HPF)

Intermittent mild hypotension or persistenttachycardia

Persistent abdominal signs/symptoms

Potential to decrease # of nontherapeuticlaparotomies


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PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME

ON FAST EXAM

Hemoperitoneum score on ultrasound a better predictor ofneed for therapeutic laparotomy than admission bloodpressure and/or base deficit.

Hemoperitoneum characterized by measurement anddistribution, scored

Ultrasound score >=3 statistically more accurate thancombination of SBP and base deficit in determining whichpatient 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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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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SPLENIC INJURIES Often arterial hemorrhage, therefore nonoperative

management less successful.

Predictive factors for nonop success:

Localized trauma to flank/abdomen Age


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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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DUODENAL AND PANCREATIC INJURY

Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitonealair on plain abdominal films.

DPL unreliable.

At laparotomy, central upper abdominal retroperitoneal hematoma, bilestaining, 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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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, needfor 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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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, ischemiafrom mesenteric vascular injury; usually presents w/in days.


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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 Trauma

Evaluation

Any penetrating wound

between nipples and gluteal

crease = potential intra-

abdominal injury.

Stab wounds: stratify based

on location

GSW: higher potential forserious injury.


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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 organinjury

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 thannegative laparotomy


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Stab Wounds: Stratification by loci

Lower Chest

Anterior Abdominal

Flank

Peristernal Potential

Mediastinal

Back


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Lower Chest

Anterior AbdominalExplore locally, manage

expectantly with serial PE

Flank


Mediastinal

Back


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Lower Chest



Flank

explore locally

triple contrast CT


Mediastinal

Back


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Lower Chest



Flank

explore locally

triple contrast CT


Mediastinal

Back

admit for obs


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Lower Chest

?Thoracoscopy,

Laparoscopy



Flank

explore locally

triple contrast CT


Mediastinal

Back

admit for obs


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Lower Chest

?Thoracoscopy,

Laparoscopy



Flank

explore locally

triple contrast CT


Mediastinal

CVP monitor, U/S

Observe >6h, repeat CXR

Back

admit for obs


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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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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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IMPACT OF DIAGNOSTIC LAPAROSCOPY ON

NEGATIVE LAPAROTOMY RATE

Retrospective review 817 pts who underwent ex-lap for abdominal GSWover 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 and14% nontherapeutic (remaining 2 were observed for nonbleeding liverlacs)

Sosa et al. J Trauma 1995;38(2):194


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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

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