Transcript Diagnosis & Management Of Acute Abdominal Trauma

Diagnosis & Management of
Acute Abdominal Trauma
Trauma Services
Ottawa Hospital
Economic Burden
of
Injury in Ontario 1996
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Injury death
Hosp injuries
Non hosp injuries
Total injuries
Partial perm. Disa.
Total perm. Disa.
Total annual cost
2,844
43,382
693,630
739,856
15,232
1,141
$2.9 billion
INTRODUCTION
Abdominal Trauma
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Abdominal injuries present in 7-10% of admission
Present in ~ 20% of all trauma surgeries
½ of preventable trauma death are related to
inappropriate management of abdominal trauma
Extra abdominal injuries are clues to the presence
of injuries within the abdomen
Abdominal injuries should be suspect in all trauma
Diagnostic Methods
Abdominal Trauma
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Physical examination
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P/E equivocal or misleading.!!!
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Bruises, abrasion over the abdomen
Abdominal pain or tenderness
Absent bowel sounds
Unexplained hypotension
Peritoneal sign falsely negative in 40%
Peritoneal sign falsely positive in 20%
10% of all injuries are initially overlook
WHY?
PHYSICAL EXAMINATION
Abdominal Trauma
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Physical examination unreliable
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Head trauma
Spinal cord injuries
Alcohol intoxication
Use of illicit drugs
Injuries to adjacent structure
Significant amount of blood present
Analgesia
CLASSIFICATION
Abdominal Trauma
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Penetrating
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High velocity
(85% penetrate peritoneum)
Low velocity
(95% need surgery)
Stab(1/3 do not penetrate the peritoneum, of those 50%
need Sx)
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Blunt trauma
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High energy transfer (car accident)
Low energy transfer (fall, fight)
Mandatory Exploration
Abdominal Trauma
Anterior abdominal gunshot
Stab
Local exploration
–
Penetration of the fascia??
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DPL
Laparoscopy
Laparotomy
Serial observation
Surgeon’s expertise
Initial management for stab wounds
Blunt Injuries
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Physical examination
Investigation
Case presentation
Specific organ injuries
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Liver
Spleen
Small bowel
Epidemiology
Injuries From Motor Vehicle Passenger Restraints
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Decrease mortality from MVC
Increase morbidity
Seat belt syndrome
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Lap belt injury in children
C-spine injury
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Air bag
Blunt Injury
Abdominal Trauma
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Spleen
25%
Liver
15%
Hollow viscus 15%
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Ileum
Sigmoid
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Kidney
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Retroperitoneal
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Mesentery
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12%
13%
5%
Compression
Crushing
Shearing
Avulsion
Physical Examination
Abdominal Trauma Evaluation
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BP and Pulse trend
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Inspection
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Seat belt mark
Skin lacerations
Previous surgery scar
Physical Examination
Abdominal Trauma Evaluation
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Auscultation
Palpation
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Rebound tenderness
Guarding
Pregnancy
Pelvic instability
Physical Examination
Abdominal Trauma Evaluation
Rectal examination
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Prostate
Rectal tone
Vaginal examination
Gluteal fold
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Penetrating injuries = abdominal injuries
Tube Insertion
Abdominal Trauma Evaluation
4-
Gastric tube
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Relives distention
Decrease risk of unattended vomiting
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But can induce it , risk of aspiration !!!
Caution
Facial fracture/basilar skull fracture
Tube Insertion
Abdominal Trauma Evaluation
Urinary catheter
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Monitor urinary output
Caution
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Inability to void
Pelvic fracture
Blood at the meatus
Scrotal Ecchymoses
High riding prostate
retrograde
urethrogram
U/S
Special Diagnostic Studies
Abdominal Trauma Evaluation
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DPL
U/S
Ct abdomen & pelvis
X-Ray
Abdominal Trauma Evaluation
C-spine
Chest AP
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+/- paper clips for penetrating injury
High association of chest injuries and
abdominal injuries
Free air?
Pelvis
+/- paper clips for penetrating injury
Others X-Ray
Abdominal Trauma Evaluation
Urethrography
5. ? IVP for hematuria
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IV contrast
Keep good urinary output
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6.
Better CT scan
Spine fracture
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Chance Fracture
20% small bowel injuries
Case Presentation
J.D. (3265709) -1
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47 year old male
Car felt on his Rt chest, LOC at scene?
RUQ & Rt chest pain & deformity Rt shoulder
A good air entry
B Rt chest pain and bruising
C Pulse 92, Bp 120/90
HgB 140
EKG , few PVC, CK 1485, Triponin t < .05
D GCS 15
E Chest abrasions Rt side
Case Presentation
J.D. (3265709) -2
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Ct scan
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Abdomen
Chest Xray
CT scan
J.D. (3265709) -2
Case Presentation
J.D. (3265709) -2
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Ct scan
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Grade III liver laceration
Intra abdominal free fluid
HgB decrease to 93
Liver injury
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85 % observation
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10% -15% mortality
15 % Laparotomy
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60 % mortality
Surgical management
A significant liver injuries will not heal
spontaneously and surgical intervention
is the only acceptable approach for it
Pringle 1908
Once the diagnostic of Hemoperitoneum
has been made, routinely the next goal
of the surgeons will be to prepare the
patient for surgery as rapidly and
efficiently as possible
Sclafani 1991
Surgical management
(cont’d)
Isolated severe blunt liver injury may be
managed nonoperatively with better survival
and less blood products use.
Grindlinger 1998
TIP
Patient selection
Type of Trauma
Age
Associated injuries
Resuscitation
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ATLS
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Patient ‘s clinical condition
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Persistent or recurrent hypotention
Hemorrhage
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Prompt control of bleeding
Judicious volume restoration
Maintenance of pH and To
TIP
Duration of shock
more critical than
the amount
of blood transfused
Blunt Liver Trauma Protocol
1998
BP>=100
HR <= 100
GCS >3
Stable
CT Scan
Liver Injury
Class 1&2
<= 4 units/24hr
Conservative
management
> 4 units/24 hr
Liver Injury
Class 3,4,5
OR
Unstable <90
Lavage
assoc abd. inj.
OR
Outcome
Age
Syst BP
Nonoperative
38
106
Operative
48
122
HR
91
102
Transfusions
1.7
10
ER fluids
2,500
3,000
ISS
13
25
LOS
11.8
37
# associ. inj
67%
100%
J Trauma;1998, 45,360
Outcome
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Nonoperative
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Less blood
mortality 15% Vs up to 63%
LOS shorter
TIP
decision to treat
is base
on the patient stability
Spleen Injuries
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Diagnosis
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CT scan will save 70 % of spleen
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Hemodynamic instability
LUQ pain
Left shoulder pain
Observation X 72 hr
Healing over 6 weeks
OPSI
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(overwhelming post Splenectomy infection)
< 1% of splenectomy , increase in children
Small Intestine Injuries
Epidemiology
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15% of all laparotomy
High index of suspicion required
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Serial examination
DPL diagnostic in 95 %
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Enhance by enzyme
Increasing success with CT and laparoscopy
Delay in diagnosis increase M & M
Retroperitoneal air
Blunt Trauma in Pregnancy
Abdominal Evaluation
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½ Injuries due to MVA
Increase incidence of splenic injury and
retroperitoneal bleed
Placenta abruption
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2-5% minor injuries
20-50% in major injuries
Blunt Trauma in Pregnancy
Treatment
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Multidiciplinary approach
Stabilization of mother status
Avoid venocaval compression
Used shielding during X-Ray
Aggressive Hypotention treatment
Establish gestational age
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Ultrasound
C-section…Group decision
Blunt Trauma in Pregnancy
Treatment-2
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Abdominal evaluation
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DPL supraumbelical approach
CT scan (5-10 cGy, Max is 10cGy)
Pelvic X-ray
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Pelvic fracture: associated with fetal skull #
Unstable pelvic fracture = c-section (10%)
Monitoring in labor & delivery room
Rh- : RhiG within 72 Hours
Epidemiology
Multivariate Odd Ratio From 16,000 Patients
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Gross hematuria
Admission hypotension
Lower ribs fracture
Hemo/pneumothorax
Abdominal wall hematoma
Base deficit(HCO3 < 21)
Pelvic fracture
3.62
3.53
2.58
2.49
1.96
1.77
1.5
(Brad Chushing)
What’s New in Abdominal Trauma
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Diagnostic
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Ct, U/S
Laparoscopy its impact is coming
Therapeutic
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Nonoperative management
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Spleen & liver
Non operative for liver gunshot
“Damage control” laparotomy
“Abdominal compartment syndrome”