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Abdominal trauma
- 1. F.Sanginabadi.MD Emergency Resident OfKurdistan University 2017
- 2. Types of AbdominalTrauma Penetrating Trauma Blunt Trauma
- 3. Penetrating Abdominal Trauma Managmentbefore 1960 Mandatory surgery Shaftan intruduced the concept of selective laparatomy and serial observation - Careful integration of P/E local wound exploration (LWE( - US - CT - Laparoscopy and rarely DPL
- 4. Penetrating Abd Traumacontinued Stab wound 3 times more than Firearm Firearms responsible of 90 percent mortality Smal intestine, colon, liver most likely organs to sustain injury Stab wounds of the abdomen occur most commonly in the upper qudrants , the left more commonly than the right
- 5. Gunshot Wounds- Ballistisc The magnitude of the injury is proportional to the amount of kinetic energy imparted by the bullet to the victim ,according to the following equation: E= 7000mv2/2g E is kinetic energy M is the mass of bullet V is the velocity of the bullet G is gravitational acceleration The impact velocity is the most important of wounding capability which depends on the distance between the firearm and the victim,the muzzle velocity and various charactristics of the missile
- 6. Missile velocities Low= slower than 1100ft/s Medium = 1100-2000 ft/s High faster than 2000-2500 ft/s
- 7. Difference between GSWand shotgun
- 8. Shotgun wound classification Long rane more than 7 yards and penetration of subcutaneous and deep facia only >25cm Distance of 3 to 7 yards and large number of perforated structures 10-25 cm Wounds at point blank range less than 3 yards involve a massive destruction of tissue <10cm
- 9. History of PAT Stab Wounds. It is helpful to obtain information regarding the mode of injury from the patient, paramedic, or witnesses. The number of stabs inflicted, type and size of the instrument, posture of the victim relative to the direction of assault, estimated blood loss at the scene, time of injury, and response to fluids should be sought.
- 10. Physical Examination inPAT In cases of penetrating trauma, inspecting the abdomen for entrance and exit wounds may help determine the path of injury. Distention can occur as a result of pneumoperitoneum, gastric dilation, or ileus produced by peritoneal irritation. An ecchymotic discoloration of the flanks (Gray-Turner sign) or umbilicus (Cullen’s sign) indicates retroperitoneal hemorrhage, but these signs are usually delayed for 12 hours to several days.
- 11. DIAGNOSTIC STRATEGIES Laboratory -Hematocrit. - WBC has little value Pancreatic Enzymes. Neither serum amylase nor lipase is useful in the evaluation of acute abdominal trauma. Base Deficit. Metabolic acidosis in the setting of trauma can suggest the presence of hemorrhagic shock. Liver Function Tests. Elevated serum transaminases can result from hepatic trauma but do not distinguish minor contusions from severe injury. Toxicology Analysis.
- 12. DIAGNOSTIC STRATEGIES continue Radiology The chest radiograph and anteroposterior pelvic films can be invaluable in some cases of penetrating and blunt trauma, depending on the presentation and results of initial evaluation. Plain abdominal films can demonstrate the location or track of the missile(s) in gunshot and shotgun injury but are of little value in blunt trauma or nonprojectile penetrating trauma, particularly if CT imaging of the abdomen is anticipated.
- 13. Computed Tomography Advantages.In most situations, CT scanning has supplanted DPL because of its higher predictive ability for operative lesions and because it is noninvasive. Disadvantages. Disadvantages of CT scanning include relative insensitivity for injury of the pancreas, diaphragm, small bowel, and mesentery, although detection of these injuries is improving. CT scanning remains the cornerstone of diagnosis.
- 14. Bedside Procedures UltrasonographyUltrasonography’s primary role is detecting free intraperitoneal blood after blunt trauma. FAST -Portable - Non invasive - High sensitivity and specificity DPL: Diagnostic Peritoneal Lavage Local wound exploration Special procedures: Laparoscopy
- 19. A: Nl B:positive morison C: positive perisplenic D: positive in sagital retrovesical
- 23. Blunt Abdominal Trauma Greaterrisk of mortality than penetrating injuries - The spleen most often injured - Liver is the second - Intestine most likely hollow viscus to be damaged The automobile is the major cause of Blunt abdominal trauma 85- Percent of pediatrics injury MVCs snoisilloc elcihev rotom (( Are responsible for most of the morbidity and mortality in case of trauma in children
- 24. Patho physiology - Suddenraise in intra abdominal pressures can cause rupture or burst injury of a hollow organ - Compression of abdominal viscera between the applied force to the anterior wall and the posterior thoracic cage or vertebral column produces a crushing effect. - Finally, acceleration and deceleration forces affecting both hollow and solid viscera cause organs and vascular pedicles to shear, especially at relatively fixed points of attachment.
- 25. Seatbelt Injuries. Unrestrainedfront and rear seat passengers are at unequivocally greater risk of intra-abdominal injury than their restrained counterparts. The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries, compared with older systems. The pathogenesis is usually the compression of bowel between the belt and the vertebral column. Occasionally, an acute , short, closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures. The resultant injury is primarily a contusion or perforation of the intestines or a tear of the mesentery.
- 26. Seatbelt Injuries continue Approximately one fourth of these patients develop evidence of a hemoperitoneum secondary to mesenteric lacerations. In the remainder, the intestinal injury most commonly involves the jejunum, and the initial signs and symptoms are often absent or considered insignificant. The “seatbelt sign,” contusion or abrasion across the lower abdomen, is found in less than one third of patients with abdominal injuries caused by lap belts. Its presence, however, is highly correlated with intraperitoneal pathologic lesions.
- 27. Iatrogenic Injuries. Artificialventilation can lead to gastric distention, particularly in children. External cardiac compressions have produced splenic, hepatic, and gastric injuries. If hypotension occurs after cardiopulmonary resuscitation, an abdominal injury and hemorrhage are considered along with cardiogenic shock. Tube thoracostomy has resulted in injury to the liver and spleen.
- 28. Pediatrics ABT. Achild’s abdomen has poorly developed musculature and a relatively smaller anteroposterior diameter. These factors increase the vulnerability of abdominal contents to compression between a blunt anterior force and the solid posterior vertebrae. The rib cage is extremely compliant in children and less prone to fractures but nonetheless provides only partial protection against splenic and hepatic injuries. Finally, the bladder is less protected by the pelvis in children, exposing it to greater risk of injury.
- 29. History The patient’shistory may be unobtainable, elusive, or temporarily deferred while resuscitative measures are carried out. When the situation permits and a reliable source is available, certain information is valuable. Abdominal pain can be localized, as it sometimes is in the left upper quadrant with a splenic injury, or diffuse, as in septic peritonitis subsequent to bowel perforation. Pain referred to the testicle is compatible with a retroperitoneal injury and is seen most commonly with urogenital and duodenal trauma.
- 30. Pediatrics Hx inBAT it is important to inquire about vaginal bleeding or discharge and rectal bleeding and to examine the rectum and vagina for foreign bodies. Such objects may be inserted by inquisitive children or by adults during acts of child molestation.
- 31. Physical Examination Thephysical examination of a hemodynamically unstable patient is performed coincident with therapy, but care and thoroughness are not precluded by these circumstances. Chest trauma itself is a risk factor for coincident intraperitoneal pathology. All of the patient’s clothing should be removed, and a careful inspection of the patient’s body should be conducted, to include the scalp, perineum, skin folds, and beneath the hair.
- 32. Physical Examination continue Hypotension in the acute stage results from hemorrhage that is most often from a solid visceral or vascular injury. Traumatic pancreatitis may produce significant third- space fluid loss, but hours to days are usually required for this to appear, and shock is an uncommon presentation. a known extra-abdominal source of hemorrhage does not mitigate the need to evaluate the peritoneal cavity.
- 39. FAST Four ViewTechnique: Morrison’s pouch (hepatorenal) Douglas pouch (retropelvic) Left upper quadrant (splenic view) Epigastric (View pericardium)
- 40. Grade 1 SPLENICINJURY
- 42. Sma llbowel edema concerning for hollow viscus injury
- 43.