pongsasit singhatas, m.d. department of surgery faculty of ... · passes into abdominal cavity 31...

PONGSASIT SINGHATAS, M.D. Department of Surgery

Faculty of Medicine, Ramathibodi HospitalMahidol University

Patient survive

Low morbidity

GOOD JUDGMENT COMES FROM

EXPERIENCE

EXPERIENCE COMES FROM

BAD JUDGMENT

Airway and Breathing first

Solid organ and Vascular injury => C

Hollow viscous injury => Sepsis

Investigate and assessment of abdomen base on three group

1)Normal abdomen

2)Equivocal require investigation

3)Obvious abdominal injury

Diagnosis modalities

1) PE

2) DPL

3) FAST

4) CT scan

5) Diagnostic laparoscope

Hemodynamically normal patient

Full evaluation and decision to surgery or

non-operative management

Hemodynamically stable patient

Will benefit from investigation aimed to

- Patient bled into abdomen ?

- Bleeding has stopped ?

- Hollow viscous injury ?

Hemodynamically unstable patient

Try to define bleeding is taking place e.g. pelvis

or abdominal cavity

FAST quicker than DPL but operator dependence

Negative DPL => very clear that the intra

abdominal bleeding is unlikely in unstable patient

Negative Exporation => Survive

Positive Unexploration => Dead

เจ็บฟร,ี เสียหน้า, เสียเวลา

Operative complication (GA, wound, adhesion)

Communication with patient and relative

Except Negative Exploration in Pelvic Fx

Unstable vital sign with

abdominal cause

or

Peritonitis

(Diffuse Abdominal tender)

Bowel content

Bile

Urine

Pancreatic juice

Blood

Difficult to exam in Head injury

Cord injuryIntoxication

Adequate analgesia

Never mask abdominal symptom

Make abdominal pathology easier to assess

- Clear physical sign

- Co-operative patient

FAST in unstable patient Positive => explore laparotomy

Equivocal => DPL/DPA or explore laparotomy

Negative => Find other bleeding, if not found DPL/DPA or explore laparotomy

No ultrasound available =>DPL/DPA

Not sent unstable patient to CT room

Abdominal sign Pelvic fracture with lower abdominal sign

CT or FAST not available

No other source in hemodynamic unstable

Distinguish blood from other type of fluid

DPA => gross blood in unstable patient

Trauma Mattox Edition6

Not BP only

Hypertensive patient ??

Sign of poor tissue perfusion

4 classification of hypovolemic shock

And

Responsibility after fluid resuscitation

Class I Class II Class III Class IV

For 70 kg male

2000 mLof isotonic solution in adult; 20 mL/Kg in children

Solid organ injury => liver, spleen, kidney,

pancreas

Vascular injury with interventionist

Need ICU

Need OR available

Need Surgeon available

Necessary to CT scan ??

- Triple contrast

- Solid parenchymal organ injury

- Free air (Plain film abdomen)

- Free fluid with Hounsfield Units

- Contrast extravasations (lumen and vessel)

- Injury grading

Limitation

- Hollow viscus

- Mesenteric injury

- Diaphragmatic injury- Bladder injury (need CT cystogram)

Trauma Mattox Edition6

Unstable Stable

FAST Positive EL CT

FAST Equivocal DPA +/- EL CT

FAST Negative Find other

bleeding, if not found DPA +/- EL

Repeat FAST

ObserveCT ??

CT not available ???

Not routinely

Stab wound

Anterior abdomen

No indication in Flank or back

Under local anesthesia

Positive => Penetration of posterior fascia

Rarely practice in trauma center

Trauma Mattox Edition6

Serial PE

Observe 24 hr

Ideal same surgeon

Frequent check V/S

Abdominal sigh every 4 hr

Persist local symptom => other modality evaluated

DPL

Unstable with other cause bleeding

Stable R/O hollow viscus or diaphragmatic injury

FAST

Not recomment

Routine laparotomy both stab and GSW

Increase conservative in stab woundLaparotomy in GSW

More conservative in GSW

Not routine in

anterior stab

wound

Recommend in

- Stab wound at

flank and back (15%

require surgical repair)

- GSW

Triple contrast

Wound tract

evaluated

Free air, free fluid

Contrast

extravasate

Intraluminal

contrast leak

Bowel wall defect

Trauma Mattox Edition6

Peritonitis

Unstable vital sign

Blood replacement??

Most common cause in trauma

Presumed hemorrhagic shock until proven

otherwise

Fluid resuscitation in early signs and

symptoms of blood loss

Principle is Stop the bleeding

and replace the volume loss

Whole blood is superior than component

therapy

PRBC:FFP ratio of 1:1 or 2:1

Platelet require in blood loss greater than

1.5 blood volume

อุดรูรั่วและเติมน ้าให้ทัน ถ้าตุ่มแห้ง => เลือดหมดตัว => ตาย

Exsanguination = Extensive Hemorrhage

- Large syringe connect to pressure source (human hand)

- IV pressure bag

- Pneumatic external pressurized intravenous infusion system

Increasing hematocrit and decreasing temperature => Increase blood viscosity

Controlled resuscitation, balance

resuscitation, permissive hypotension

Keep SBP 80-90 mmHg or 100 mmHg if head injury is suspected

Penetrating trauma with hemorrhage

No evidence in blunt trauma

Manual of Definitive Surgical Trauma Care, Boffard

Delay aggressive fluid resuscitation

until definitive control

Prevent additional bleeding

Balance of organ perfusion

and

Risk of rebleeding

(accept a low normal blood pressure)

Manual of Definitive Surgical Trauma Care, Boffard

Desire to reassess the intra-abdominal content (directed re-look)

Evidence of decline of physiology reverse

1)Initial body temperature < 34 C

2)Initial acid-base status

- Arterial pH <7.2

- Serum lactate > 5 mmol/L

- Base deficit <-15 mmol/L in patient <55 years

or <-6 mmol/L in patient >55 years

Manual of Definitive Surgical Trauma Care, Boffard

3)Onset coagulopathy

PT >16 sec or PTT >60 sec

>50% of normal

4)Other condition

- >10 unit blood

- SBP <90 mmHg more than 60 min

- Operating time >60 min

Control

1. Bleeding2. Contamination

Thoracotomy if indication

Laparotomy if indication

In unstable patient, what is first?

=> depend on ICD content

=> prep both chest and abdomen

Diaphragmatic injuryDifficult to diagnosis

Both hemothorax and hemoperitonem in one penetrate wound

Bowel content or NG tube at chest (Lt) from film chest in blunt

Should be repair by non absorbable

Laparoscopic diagnosis and repair is standard

Can repair from thoracotomy or laparotomy

11 in 28 (39%) mortality in unstable pelvic Fx

with laporotomy

FAST positive => retroperitoneal hematoma

passes into abdominal cavity

31 in 80 unstable pelvic Fx patients with free

fluid and undervent laparotomy

1 in 31 patient show retroperitoneal

hemaotoma alone

Mortality rate 35% in laparotomy group

J.K. Bryceland, Injury, Int. J. Care Injured 2008

Steffen R, J Trauma.2004;57:278 –286.

Trauma Mattox Edition6

Unstable

Secondary brain injury- Hypovolemic shock

- Polycompartment syndrome

Severe HI associated DIC- Now, conservative in solid organ injury is accept

- Threshold for laparotomy lower than non HI

Laparotomy or CT head first ??Laparotomy in patient with GCS 2T ??

Trauma Mattox Edition6

Trauma Mattox Edition6

Technique for temporary control of hemorrhagePerihepatic packing

Electrocautery or argon beam coagulator

Pringle’s manoeuvre

Hemostatis agent and glues

Hepatic suture -> large curve needle Chromic

Technique for temporary control of hemorrhageFinger fracture hepatotomy and

vessel ligation

Tract temponade balloon (Sengstaken tube)

Tractotomy and direct suture

Mesh wrap

Hepatic artery ligation

Technique for temporary control of hemorrhageHepatic resection

Hepatic vascular isolation

Atriocaval shunt

Veno-venous bypass

Hepatic vascular isolation

Pringle’s manoeuvre

Clamp IVC above Rt kidney (Suprarenal)

Clamp IVC above live (Suprahepatic)

Atriocaval shunt

Good exposure

Proximal and distal control

Anatomical distortion from hematoma

Active bleeding

- Pressure first

- Supraceliac control or Lt anterolateral

thoracotomy in aorta injury

- Supradiaphragmatic control in IVC

Manual of Definitive Surgical Trauma Care, Boffard

Retroperitoneal organ

In early of injury, abdominal exam is difficult

FAST or DPL maybe negative

Retorperitoneal free air in plain film

or CT)

High mortality if delay diagnosis

Should be Kocherization and open lesser sac in blunt abdominal injury

Trauma Mattox Edition6

Duodenal Inj

Trauma Mattox Edition6

Pancreatic Inj

Non-operativeIndication for surgery follow non-operative

Hemodynamic instable

Evidence of continued splenic hemorrhage

Associate intra-abdominal injury requiring

surgery

Replacement of more than 50% of blood volume

Spleen not active bleeding

-> left alone

Splenic surface bleeding only

-> packing, diathemy or fibril glue

Minor lacerations

-> absorbable suture use pledget, omental patch may be place

Splenic tears1) Mesh wrap -> absorbable mesh e.g. Vicryl

wrap from hilum and around parenchyma

2) Partial splenectomy -> ligating segmental vessel at hilum and seen demarcation ischemic pole

3) Splenectomy

Option

Primary repair

Resection

+/- anastomosis

+/- proximal

diversion

Diversion only

Depend on

Position of injury

=> Stomach, Small

bowel, Colon

Severity of injury

Contamination

Patient status

Can not conservative Need to Laparotomy

Aim of trauma is patient survive

Different resource => different judgment

Now, try conservative but patient safety is

most important

Don’t forget call for help

Damage control if indication