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Similar to ABDOMINAL TRAUMA PRESENTATION, diagnosis
ABDOMINAL TRAUMA PRESENTATION, diagnosis
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- 2. Abdominal trauma meansany injury occurring to abdominal cavity. In civilian life, the majority of abdominal injuries are due to blunt trauma secondary to high speed automobile accident. Penetrating injuries, often associated with wartime combat, are seen with increasing frequency in ED particularly in urban areas. The failure to manage abdominal injuries successfully, accounts for the majority of preventable deaths following multiple injuries, and this accounts for approx10% of traumatic deaths annually. INTRODUCTION
- 3. • How torecognize the trauma patient with an abdominal injury – Anatomy • How to manage the patient with an abdominal injury in the initial stage • Damage control resuscitation • How to evaluate the abdomen – Different modalities & whole body scan • Management – According to injury OBJECTIVES
- 4. Overall, 3rd leadingcause of death. 2/3 rd occur in males with a peak incidence 14 – 30 yrs. ¾ attributable to RTA. In blunt abdominal trauma the spleen and liver are the most commonly injured organs and contribute to a mortality of 8.5%. Gunshot and stab wounds account for 90% of penetrating trauma. Penetrating injury has a higher mortality of up to 12%and accounts for 1/3rd of all abdominal trauma. Combination injuries from bombs and explosive devices are on the increase Abdominal trauma more common in the urban set. EPIDEMIOLOGY
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- 7. ANATOMY Intrathoracic abdomen Trueabdomen Pelvic abdomen Retroperitoneal abdomen
- 8. ANATOMY Intrathoracic Abdomen Liver Spleen Stomach Diaphragm Inaccessible to palpation
- 9. ANATOMY True Abdomen Smallintestine Large intestine Urinary Bladder (when distended) Uterus (when gravid)
- 10. ANATOMY Pelvic Abdomen Urinarybladder Urethra Small bowel Reproductive organs Iliac vessels Lower part of retroperitoneal space Rectum
- 11. ANATOMY Retroperitoneum Kidneys Ureters Pancreas Duodenum except pyloric part Ascending and descending colon Abdominal Aorta Inferior vena cava Potential space, Behind true peritoneal cavity.
- 12. ANATOMY Solid Organs Liver Spleen Pancreas Kidneys Adrenals Ovaries (female) Haemorrhage Shock Hollow Organs Stomach Intestines Gallbladder Urinary bladder Uterus (female) Peritonitis
- 13. BLUNT ABDOMINALTRAUMA PENETRATING ABDOMINAL TRAUMA CLASSIFICATION OF INJURIES
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- 16. BLUNT ABDOMINAL TRAUMA High energy transfer (Car accidents) Low energy transfer (Fall, fight) Motor vehicle crash 50- 60% Blows to the abdomen 15% Falls 6-9%
- 17. BLUNT ABDOMINAL TRAUMA MECHANISMOF INJURY Compression crush between solid objects such as the steering wheel/seat belt & the vertebrae
- 18. BLUNT ABDOMINAL TRAUMA Shearing Organs continue forward motion, causing tear or rupture from stretching at points of attachment
- 19. Spleen (40-55%) Liver (35-45%) Smallbowel (5-10%) Retroperitoneal hematoma: 15% BLUNT ABDOMINAL TRAUMA
- 20. Blunt abdominal injuriescarry a greater risk of morbidity and mortality than penetrating abdominal injuries BLUNT ABDOMINAL TRAUMA
- 21. associated withsevere trauma to multiple intraperitoneal organs and extra-abdominal systems altered mental status Peritoneal signs are often subtle and may be obscured by other painful injuries Up to 20% of patients with hemoperitoneum have normal abdominal exams on initial presentation. BLUNT ABDOMINAL TRAUMA
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- 23. MECHANISM Stab wounds Knives Screwdrivers Broken glass/bottles Coat hangers Rods Gunshot wounds Shot guns Hand guns Rifles Bombs PENETRATING ABDOMINAL TRAUMA
- 24. Stab wounds Liver(40%) Small bowel (30%) Diaphragm (20%) Colon (15%) Multiple in 20% of cases Most commonly in the upper quadrants, the left more commonly than the right. PENETRATING ABDOMINAL TRAUMA
- 25. Gunshot wounds Smallbowel (50%) Colon (40%) Liver (30%) Abdominal vascular structures (25%) . PENETRATING ABDOMINAL TRAUMA
- 26. Gunshot wounds Extensivetissue damage due to high energy transfer Degree of injury depends amount of kinetic energy imparted by the bullet to the victim mass of the bullet and the square of its velocity K=mv2 Low velocity- Handguns (750-1400 ft/sec) Medium velocity- Shotguns(1400 ft/sec) High velocity- Rifles (>2200 ft/sec) Distance External contaminants tend to be PENETRATING ABDOMINAL TRAUMA
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- 28. CLINICAL ASSESSMENT OFPATIENT WITH ABDOMINAL TRAUMA
- 29. Bleeding: Liver Spleen Kidneys Mesentery Pelvis (venous complexes) Bowel: Contamination Bladder: Intraperitoneal rupture Diaphragm: Mainly on the left side What Are We Worried About?
- 30. First: recognizepresence of shock or intra abdominal bleeding Second: start resuscitative measures for shock / bleeding Third: determine if abdomen is source for shock or bleeding Fourth: determine if emergency laparotomy is needed Fifth: complete secondary survey, lab, and radiographic studies to determine if “occult” abdominal injury is present Sixth: conduct frequent reassessments ABDOMINAL TRAUMA Diagnosis & Treatment Priorities
- 31. HAEMODYNAMICALLY “NORMAL” Investigationscan be completed before treatment is planned HAEMODYNAMICALLY “STABLE” Limited investigations Non operative vs Operative HAEMODYNAMICALLY “UNSTABLE” Investigations suspended Immediate surgical control of bleeding ABDOMINAL TRAUMA
- 32. HISTORY PHYSICALEXAMINATION INVESTIGATIONS CLINICAL ASSESSMENT
- 33. Blunt trauma Identificationof the injury History from prehospital care team or transferring hospital Mechanism of injury Details about accident Damage to car Velocity Steering wheel damage Type of seatbelts used Air bags deployed All patients involved in deceleration injuries and bicycle injuries should be suspected of having intraabdominal injury HISTORY
- 34. Penetrating trauma: Numberof shots or stabs Type of weapon Distance between firearm and victim HISTORY
- 35. Mainly is partof secondary survey Inspection Palpation Percussion Auscultation CLINICAL EXAMINATION
- 36. Inspection Abrasions /lacerations Seat belt sign Entrance & exit wounds Distension Scars from prior surgeries Masses or bulges Important to logroll patient and assess back also CLINICAL EXAMINATION
- 37. GREY TURNER SIGN Bluishdiscoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancreas, kidney, or pelvic fracture. CLINICAL EXAMINATION
- 38. CULLEN SIGN Bluishdiscoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage. CLINICAL EXAMINATION
- 39. Palpation Tenderness Guarding Mass Crepitus Differentiate lower rib tenderness from true abdominal tenderness Palpate back Pelvic wings for stability & tenderness CLINICAL EXAMINATION
- 40. Percussion Should check onall 4 quadrants Tympanic - ileus or bowel obstruction Dull - intra abdominal bleeding or fluid Tender - correlate with tender areas on palpation CLINICAL EXAMINATION
- 41. Auscultation Should listen overall 4 quadrants Absent sounds - ileus from injury or bleeding High pitched sounds – bowel obstruction Some vascular injuries – audible bruits Bowel sounds in chest – ruptured diaphragm CLINICAL EXAMINATION
- 42. Blood aturethral meatus – Urethral injury Rectal examination - Gross blood – Pelvic fracture - High riding prostate – Urethral injury Vaginal examination CLINICAL EXAMINATION
- 43. Plain X-rayschest, abdomen, and pelvis Focused assessment with sonology in Trauma (FAST) Diagnostic peritoneal lavage (DPL) Diagnostic Laparoscopy Contrast studies, CT scan. Urethrography Cystography IVU Angiography INVESTIGATIONS
- 44. Routine Xrays inTrauma Cervical spine Chest Pelvis Abdomen – in abdominal trauma Xray Chest Right lower ribs fracture – Liver Left lower ribs fracture – Spleen Gut loops in thoracic cavity – Diaphragm rupture Xray Abdomen Free intraperitoneal air – intestinal perforation Loss of psoas shadow – retroperitoneal haemorrhage Xray Pelvis Pelvic fracture – Severe pelvic haemorrhage Penetrating abdominal injury Markers at external wounds – trajectory PLAIN RADIOGRAPHY
- 45. Ultrasound (sonar) imagingis used to detect presence of free blood, either in the abdominal cavity or in the pericardium Six areas Pericardial Perihepatic Perisplenic Right & Left paracolic gutters Pelvis Rapid, portable, non-invasive, bed side Accurate at detecting >100 ml of fluid Cannot detect hollow viscus injury Unreliable in penetrating injury FOCUSED ASSESSMENT WITH SONOGRAPHY IN TRAUMA (FAST
- 46. Assess the presenceof blood in the abdomen Positive DPL criteria > 10 ml blood on initial aspiration RBC count> 100,000 / mm3 (blunt) RBC count >10,000 / mm3 (chest penetrating wounds) WBC count > 500 / mm3 Stool or food fibers or bile Lavage fluid exits via chest tube, NG tube, or foley Elevated amylase in lavage fluid DIAGNOSTIC PERITONEAL LAVAGE
- 48. Gold standard forintra abdominal injury Only indicated in hemodynamically stable Sensitive in detecting Intra peritoneal bleed Individual organ injury Retroperitoneal injury Should be done with iv contrast Duodenal injury – oral contrast Rectal or distal colonic injury – rectal contrast Inappropriate for unstable patient CT SCAN
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- 50. A –Airway and C-spine B – Breathing C – Circulation and hemorrhage control D – Disability E – Exposure PRIMARY SURVEY
- 51. Oxygen administration ETT – hypotensive, GCS < 8 Two large bore cannulas in upper limbs Normal saline/ Ringer’s lactate Monitoring vitals Blood sampling – routine & cross match Foley catheter NG tube Analgesics Antibiotics Tetanus prophylaxis RESUSCITATION
- 52. Complete abdominal examination Evaluation Normal Stable Unstable Can patient be investigated? Operative vs Non operative ASSESSMENT
- 53. Signs ofperitoneal injury Unexplained shock Evisceration Positive DPL, Fast, CT Deterioration of findings during routine follow up FINAL STEP IN ABDOMINAL TRAUMA LAPAROTOMY OPERATIVE OR NON OPERATIVE
- 54. 1. Shock 2. Peritonitis 3.Blood out of NG tube or on rectal exam 4. Intraperitoneal bladder rupture 5. Diaphragmatic rupture INDICATIONS OF LAPAROTOMY BLUNT TRAUMA
- 55. 1. Shock 2. Peritonitis 3.Evisceration 4. Weapon still in situ 5. Blood out of NG 6. Blood on rectal exam 7. Gross haematuria INDICATIONS OF LAPAROTOMY PENETRATING TRAUMA
- 57. Patients with majorexsanguinating injuries may not survive complex procedures DAMAGE CONTROL SURGERY
- 58. STAGES I Patient selection IIControl of haemorrhage and control of contamination III Resuscitation continued in the intensive care unit IV Definitive surgery V Abdominal closure DAMAGE CONTROL SURGERY
- 59. DAMAGE CONTROL SURGERY PARTI – OR Control of hemorrhage Control of contamination Intra abdominal packing Temporary closure PART II – ICU Core rewarming Correct coagulability Maintain hemodynamics Ventilatory support Injury definition PART III – OR Pack removal Definitive surgery
- 60. Indications for DCS Exsanguinating patient with hypothermia and co-agulability Inability to control bleeding by direct method Inability to close abdomen without tension Expected long operation time DAMAGE CONTROL SURGERY
- 61. Initial laparotomy steps Big arteries or veins are ligated or repaired Abdominal packing in the form of pads or rolled mesh gauze are used to control or slow venous bleeding Packs are placed above and below the injury achieving compression on both sides Four quadrant abdominal packing Small rents in the intestine repaired Devitalized gut excised and ends closed Abdomen closed without tension DAMAGE CONTROL SURGERY
- 63. Definitive operation steps 48-72 hours Removal of clots abdominal packs Complete inspection of the abdomen to detect missed injuries Restoration of intestinal integrity Abdominal wound closure DAMAGE CONTROL SURGERY
- 64. Assess abdomenas potential source of shock or bleeding Start resuscitation Complete the abdominal exam with the secondary survey Decide if emergent or urgent laparotomy needed Decide if additional diagnostic studies needed Reassess frequently Decide if transfer to a trauma center needed ABDOMINAL TRAUMA SUMMARY