blunt trauma abdomen ankit

BLUNT TRAUMA

ABDOMEN

DR ANKIT SHARMA

RESIDENT [SURGERY]

ARMED FORCES MEDICAL COLLEGE

PUNE

Scheme of presentation

Regional anatomy of abdomen

Mechanism of injury

Initial management

Examination

Investigations

Laparotomy

Indications

Approach

Management of specific injuries

Abdominal Compartment Syndrome

2

Regions of abdomen Anterior Abdomen

Superiorly – b/w costal margins

Inferiorly – Inguinal ligament &

pubic symphysis

Laterally – Ant axillary lines

Majority hollow viscera may be

involved

3

Regions of abdomen Thoraco Abdomen

Inferior to

Anteriorly: Trans-nipple line

Posteriorly: Infra-scapular line

Includes

Diaphragm, Liver, Spleen & Stomach

Full expiration diaphragm rises to 4th

ICS Abdo viscera may be injured by

penetrating wounds/ # lower ribs

4

Regions of abdomen Flank

Anteriorly – Ant axillary line

Posteriorly – Post axillary line

Superiorly – 6th ICS

Inferiorly – Iliac crest

Thick musculature – partial barrier

to penetrating wounds

5

Regions of abdomen Back

Posterior to posterior axillary line

From – tip of scapulae

To – Iliac crest

6

Regions of abdomen 7

Regions of abdomen Pelvis

Lower part of retroperitoneal and

intraperitoneal spaces

Rectum, bladder, iliac vessels,

internal reproductive organs

(females)

8

Stats

MVAs responsible for 75% of all blunt abdominal trauma

Multi-organ & multi-system injury

Solid organ injury >> Hollow viscus injury

Spleen (40-55%) > Liver (35-45%) > Small bowel (5-10%)

Retroperitoneal hematoma (15% laparotomies)

9

Mechanism of injury

CRUSHING

Direct application of a blunt force to the abdomen

SHEARING

Sudden decelerations apply a shearing force across organs with

fixed attachments

BURSTING

Raised intraluminal pressure by abdominal compression in hollow

organs can lead to rupture

PENETRATION

Disruption of bony areas by blunt trauma may generate bony

spicules that can cause secondary penetrating injury

10

Injuries from restraint devices 11

Standard initial protocol Spinal stabilization

Maintenance of ABC

IV access (double) and IV fluids

Draw and send blood for investigations, blood grouping

NG tube insertion

Urinary catheterization

12

History

Mode of injury (MVA/ direct blow/ fall from height)

Type of veh & speed

Type of collision (frontal/ lateral/ side/ rear/ rollover)

Response to pre-hospital treatment (by trauma care

personnel)

Explosion – visceral overpressure injuries (more in closed

spaces and less distance of patient from explosion)

13

Physical Examination:

Inspection

Fully unclothe the patient

Whole body thorough inspection

abrasions, contusions from restraint devices, lacerations,

penetrating wounds, impaled foreign bodies, evisceration of

omentum or small bowel, and the pregnant state

Flank, scrotum & perianal area – blood @ meatus, swelling,

bruising, laceration of perineum, vagina, rectum or buttocks

(s/o open pelvic #)

14

The classical

‘seatbelt’ sign.

The bruising on the

left breast is from

the shoulder belt

and the low

bruising to the

abdominal wall is

from the lap belt.

15


Palpation & Percussion

Tenderness (Superficial/ deep)

Rebound tenderness

Guarding (Voluntary/ involuntary), rigidity

Dullness/ shifting dullness – intraabdominal

collection

16


Auscultation

Difficult in a noisy room

Bowel Sounds +/-

Reliable only when initially present and change later

Absence of bowel sounds – non-specific

17

Pelvic Stability Testing

Pelvic hemorrhage occurs rapidly - Unexplained hypotension

Compression-distraction maneuver

Perform only once; may result in further hemorrhage

Ruptured urethra (high riding prostate, scrotal hematoma, blood @ meatus)

Limb lengthening discrepancy

Rotational leg deformity without e/o fracture

18

Others Vaginal examination

In presence of complex perineal lacerations/ pelvic # or trans-pelvic

GSW

Vaginal laceration may be seen due to pelvic # or penetrating

wounds

Gluteal examination

From iliac crest to gluteal folds

Penetrating injuries – rectal injuries below peritoneal reflection

GSWs & stab wounds – associated with intra-abdominal injuries

19

Others NG tube

Relieve acute gastric dilatation

Decompress stomach before a DPL

Remove gastric contents

Blood in NG Esophageal/ upper GIT injury (after excluding naso/

oro-pharyngeal sources)

Urinary catheter (or SPC)

Relieve retention

Decompress bladder before DPL

Monitor UO as indicator of tissue perfusion

Gross hematuria trauma to genitourinary tract & non renal

intraabdominal organs

20

INVESTIGATIONS –

Aim

To identify To decide When

(those with injury) (which ones (how quickly

need laparotomy) this must be

undertaken)

DIAGNOSTIC STRATEGY

DIAGNOSTIC STRATEGY

cont.. Complete hemogram with hematocrit

ABG, Electrocardiogram

Renal function tests

Urine analysis –

+nce of hematuria – genitourinary injury

-nce of hematuria – does not rule out it

Serum amylase / lipase or liver enzymes - se -suspicion of intraabdominal injuries

Imaging studies

Abdominal X-ray

FAST

DPL

CT Scan

Contrast studies

23

Abdominal X-ray Pneumoperitoneum – hollow viscus perforation

Ground glass appearance – massive haemoperitoneum

Dilated gut loops- retroperitoneal hematoma/ injury

Retroperitoneal air outlining the right kidney – duodenal injury

Double wall sign – air inside and outside the bowel

Distortion or enlargement of outlines of viscera – hematoma in

relation to respective organs

24

Abdominal X-ray Medial displacement of stomach – splenic hematoma

Obliteration of Psoas shadow – retroperitoneal bleeding

Pelvic bone fracture – bladder/urethral/rectal injury

Fracture vertebra – ureter injury / retroperitoneal hematoma

25

Chest X-ray Pneumothorax/haemothorax

Raised left/right hemidiaphragm – perisplenic/hepatic hematoma

Lower ribs fracture – liver/spleen injury

Abdominal contents in the chest – ruptured hemidiaphragm

26

Indications for investigating

further Unexplained hemorrhagic shock

Major chest or pelvic injuries

Abdominal tenderness

Diminished pain response due to

Intoxication

Depressed level of consciousness

Distracting pain

Paralysis

Inability to perform serial examination

27

FAST Focused Assessment Sonography in Trauma

Rapid, accurate, non invasive, inexpensive study

Operator dependant

Views

Pericardial view (Subxiphoid/ parasternal view)

RUQ view - diaphragm-liver interface and Morrison’s pouch

(Sagittal view in MAL in 10th or 11th ICS)

LUQ view - diaphragm-spleen interface and spleen-kidney

interface (Sagittal view in MAL in 8h or 9th ICS)

Suprapubic view (Transverse; before inserting foley’s)

28

FAST Low frequency (3.5 MHz) transducer; allows depth of

penetration necessary to obtain appropriate images

± Second scan 30 min after initial scan - progression

Negative FAST doesn’t rule out intra-abdominal

injury

Difficult in subcutaneous emphysema, obese and

previously operated pts

Absolute indication for a laparotomy =

contraindication for FAST

Pelvic # may decrease the accuracy

29

DPL Diagnostic Peritoneal Lavage

Rapid, invasive, 98% sensitive for intraperitoneal bleed

Indications

Patients with spinal cord injury

Those with multiple injuries and unexplained shock

Obtunded patients with a possible abdominal injury

Intoxicated patients in whom abdominal injury is suspected

Patients with potential intraabdominal injury who will undergo prolonged anesthesia for another procedure

30

DPL Open, semi-open or closed method

Gross blood aspirated – go for Laparotomy

No gross blood – instill 1 lit of warm NS (child –

10ml/kg) – gently agitate the abdomen

Adequate fluid return is > 20% of infused volume

Negative lavage doesn’t exclude retroperitoneal

injuries e.g. pancreatic or duodenal injuries

31

DPL Absolute contraindication = obvious need for

laparotomy

Relative contraindications

Pregnancy

Morbid obesity

H/o multiple abdominal surgeries

Positive if

10 ml grossly bloody aspirate before infusing lavage fluid

>100,000/μL RBCs; >500 /μL WBCs; Only 30mL blood

reqd to produce microscopically positive DPL result

↑ amylase, bile, bacteria, vegetable matter or urine +

33

DPL Hemorrhage (false positive results)

secondary to injection of local anesthetic

Incision of the skin or subcutaneous tissues

Peritonitis due to intestinal perforation from the

catheter

Laceration of urinary bladder (if bladder full)

Injury to other abdominal and retroperitoneal

structures requiring operative care

Wound infection at the lavage site (late complication)

34

Abdominal CT Scan Hemodynamically stable patient

Not in emergent need of laparotomy

± Contrast administration (non-ionic contrast)

Organ injury & extent

Retroperitoneal/ pelvic organ injuries

Can miss some GI, diaphragmatic and pancreatic

injuries

Free fluid with no hepatic/ splenic injury suspect GI

or mesenteric trauma

35

DPL Vs FAST Vs CT 36

Contrast studies Urethrography

Cystography

IVP

GI Contrast studies

37

The big question:

Which patients need Laparotomy ?

38

Small answer

Blunt abdominal trauma with hypotension with a

positive FAST or clinical evidence of intraperitoneal

bleeding

Blunt or penetrating abdominal trauma with a positive

DPL

Hypotension with a penetrating abdominal wound

Gunshot wounds traversing the peritoneal cavity or

visceral/vascular retroperitoneum

39

Small answer

Bleeding from the stomach, rectum, or genitourinary

tract from penetrating trauma

Peritonitis

Free air, retroperitoneal air, or rupture of the

hemidiaphragm

CECT findings of ruptured GIT, intraperitoneal bladder

injury, renal pedicle injury, or severe visceral

parenchymal injury after blunt or penetrating trauma

40

LAPAROTOMY Generous midline incision

Transverse incision in children < 6 yrs

Scalpel better than cautery.

Forget the bleeding from incision till definite source of bleed

found

Remove blood and blood clots with abdominal swabs

Palpate spleen and liver first and pack if fractured

Source localized direct digital occlusion (vascular injury)

or pad packing (solid organ injury)

Liver bleed – hepatic pedicle clamping with vascular clamp

(Pringle maneuver)

41

Liver bleed control 42

LAPAROTOMY Splenic bleed – clamp splenic hilum (better than packing

alone)

Rotate spleen medially

Incise lateral peritoneum & endoabdominal fascia

Spleen and pancreas can be dissected from retroperitoneum

as a composite , ant to Gerota’s fascia

43

Splenic mobilization 44

MANAGEMENT OF

SPECIFIC INJURIES

45

Liver trauma 46

Liver trauma 47

Primary aim is to arrest bleeding

Perihepatic packing is effective most of the times, if

not then perform Pringle maneuver

Difficult to perform perihepatic packing in Lt lobe

Mobilize it and compress between surgeon’s hands

Pringle maneuver

Bleeding stopped => from AHA / PV

Doesn’t stop => HVs and retrohepatic IVC is the source Packing Failed direct vascular repair ± hepatic vascular

isolation

Repair the Hepatic artery proper

Cholecystectomy if Rt hepatic artery is ligated

Liver trauma 48

Minor lacerations

Manual compression

Topical hemostats (cautery, argon beam coagulator,

gelfoam, fibrin glue, collagen)

Shallow lacerations running suture

Deep lacerations

Interrupted Hz mattress parallel to edge of laceration

Omentum to fill large defects (obliterates dead space;

source of macrophages)

Deep recalcitrant hemorrhage hepatic lobar arterial

ligation

Liver trauma 49

Repeat laparotomy within 24 hrs for pack removal

Ongoing hemorrhage – early exploration (<24h h)

Complex injuries – angioembolization

Complex injuries – typical ‘liver fever’ upto 5 days post

injury

Non-anatomical resection – stable without coagulopathy

GB injury cholecystectomy

EHBD Transaction Roux-en-Y choledochojejunostomy

Till then intubate the duct for external drainage

Complications – hemorrhage, hepatic necrosis, bilomas,

arterial pseudoaneurysms and biliary fistulas

Liver trauma - NOM 50

Basis

50-80% of liver bleed stops spontaneously

Better results of NOM in children

Significant development of CT scan in liver imaging

Initially introduced for minor injuries (1972)

Presently being used for grades III – V also

Selection criteria

Hemodynamic stability after initial resuscitation

No other visceral/ retroperitoneal injuries needing surg

Multidisciplinary team – Experienced surgeon,

Intensivist, CT scan, 24x7 OT facilities

Liver trauma - NOM 51

Failure rate significantly higher in Gd IV & V than Gd I-

III

Most common reason for intervention – co-existing

abdo injury (e.g. bleed form spleen or kidney)

Predictors of NOM failure

Advanced age

Anaemia & HTN

Active extravasation on CT

Massive blood transfusion

CT follow up for Gd I & II not necessary

Others need clinical and CT follow up

Splenic trauma 52

Splenic trauma 53

Management options

Observation

Angiographic Embolization (Gd I-III; age < 55y)

Surgery (Splenectomy/ partial splenectomy/ splenorrhaphy)

Depending upon

Hemodynamic status of pt

Grade of injury

Presence of other injuries

Medical co-morbidities

Upto 20% patients require early splenectomy

Delayed hemorrhage/ rupture can occur weeks after injury

Splenic trauma 54

Splenectomy (with auto-transplantation)

Hilar injuries

Pulverized splenic parenchyma

GD III and above + coagulopathy/ multiple injuries

Partial splenectomy – isolated polar injuries

Splenorrhaphy – cautery, argon beam coagulator,

gelfoam, fibrin glue, collagen, envelopment in absorbable

mesh, pledgeted suture repair

Bleeding edges – Hz mattress sutures + parenchymal

compression

Splenic Auto-transplantation 55

Splenic Bleeding Edges 56

Splenic trauma 57

Post splenectomy hemorrhage

Loosening of tie around splenic vessels

Improperly ligated/ missed short gastric artery

Recurrent splenic bleed

Post-op complications

Subphrenic abscess (pigtail drainage)

Pancreatic tail injury (Iatrogenic)

Gastric perforation (during short gastric ligation)

OPSI

Splenic trauma - NOM 58

Basis

Salvaging functional splenic tissue – avoids surgical &

anesthetic complications

No risk of post-splenectomy abscess

Indications

Hemodynamically stable patients (Gd I - III)

No other intra-abdominal injuries needing laparotomy

Active contrast extravasation/ blush on CT

> 70 % patients still undergo splenectomy after NOM

Higher failure rates of NOM with increasing grades of

severity

Splenic trauma – NOM 59

Absolute bed rest & NPO

6 hrly Hb check in first 24h

Allowed orally if Hb stable & no surg intervention likely

Follow-up CT: Falling Hb, abdo pain, fever, Lt shoulder

pain

Duration based on

Gd of splenic injury

Nature & severity of other injuries

Clinical Status (Incl peritoneal signs – missed hollow viscus

injury & Hb levels)

Embolization – 73-97% success rate

Stomach & Small Intestine 60

Gastric Wounds – running single layer suture (full

thickness bites)/ stapler

Partial gastrectomy – for destructive injuries

Small intestine injury < 1/3rd of bowel circumference

transverse running 3-0 PDS

Multiple injuries/ mesenteric injuries – segmental

resection and anastomosis/ stoma

Post-op ileus is obligatory

No enteral feeds for atleast 48 hrs

TEN to be started at 20mL/h once resuscitation is

complete

Duodenum 61

Duodenal hematoma – NG aspiration & parenteral

nutrition

Small duodenal perforation/ laceration – primary single

layer repair

1st part injuries – debridement & end-to end anastomosis

with gastric antrum/ pylorus

2nd part injuries – patch with vascularized jejunal graft

3rd & 4th part injuries – resection and anastomosis on Lt

side of Superior mesenteric vessels

Pyloric exclusion – high risk, complex duodenal repairs

Pancreas 62

Management depends on location of injury to

Parenchyma

Intrapancreatic CBD

MPD

Contusion (ductal system intact)/ proximal pancreatic

injuries (to Rt of SM vessels)

Non operative/ closed suction drain

Distal duct disruption (body & tail) – distal

pancreatectomy with splenic preservation

Injury to Head with duct injury – distal duct ligation with

Roux-en-Y choledochojejunostomy

Colon & Rectum 63

3 methods for colonic injuries

Primary repair

End colostomy

Primary repair with diverting colostomy

Weigh the risk of primary repair Vs colostomy

Lt colon injuries - Temporary colostomy

Other high risk pts - Diverting ileostomy with colocolostomy

Rectal injuries – loop ileostomy/ sigmoid loop colostomy

Accessible rectal injury – attempt primary repair with diversion

Extensive rectal injury – End colostomy (Hartmann’s)

Complications: Intra-abdo abscess, fecal fistula, infection,

stomal complications

Genitourinary Tract 64

90 % Renal injuries managed conservatively

Hematuria resolves in few days with absolute rest

Operative intervention – Hypotension due to

Renovascular injuries

Destructive parenchymal injuries

Persistent gross hematuria – embolization

Urinoma – Percutaneous drainage

Renal artery repair

Success rates very low

Image guided endostent placement can be attempted


Renorrhaphy

Take vascular control for proper visualization

Preserve renal capsule

Collecting system is closed separately with absorbable

sutures

Preserved capsule is closed over collecting system repair

Ureter injuries

Primary repair with renal mobilization for tension relief

Reimplantation (with psoas hitch) for distal ureter injuries

Damage control – B/L ligation + Nephrostomy

Renorrhaphy 66


Bladder injuries

Intraperitoneal injuries

Running, single layer 3-0 absorbable monofilament suture

Lap repair – if other injuries not needing repair

Extraperitoneal injuries

NOM with bladder decompression for 2 wks

Urethral injuries

Bridge the defect with Foley’s

Elective repair for strictures later

Vascular Injuries 68

ABDOMINAL COMPARTMENT SYNDROME

Symptomatic organ dysfunction that results from increased intraabdominal pressure (IAP)

Increased IAP is an under-recognized source of morbidity and mortality.

1-day point-prevalence observational trial conducted in 13 medical ICUs of six countries with 97 patients, 8% had IAP > 20mmHg.

The incidence of ACS in trauma patients is estimated to be between 2 and 9 percent.


Massive volume resuscitation in the leading cause of ACS.

Inflammatory states with capillary leak, fluid sequestration, inadequate tissue perfusion, and lactic acidosis can develop ACS.

Gastric overdistention following endoscopy has resulted in ACS.

ETIOLOGY


The IAP is usually 0 mmHg during spontaneous respiration

Slightly positive in the patient on mechanical ventilation

IAP increases in direct relation to body mass index.

Supine hospitalized patients had a mean baseline value of 6.5

mmHg.

The compliance of the abdominal wall limits the rise in IAP but

increases rapidly after a critical IAP

Critical IAP varies from patient to patient, based on abdominal

wall compliance on perfusion gradient

IAH often defined as IAP > 12mmHg

Previous pregnancy, cirrhosis, morbid obesity, may increase

abdominal wall compliance and can be protective

PATHOPHYSIOLOG

Y


CLINICAL MANIFESTATIONS

CENTRAL NERVOUS SYSTEM

Intracranial pressure

Cerebral perfusion pressure

CARDIAC

Hypovolemia

Cardiac output

Venous return

PCWP and CVP

SVR

PULMONARY

Intrathoracic pressure

Airway pressures

Compliance

PaO2 PaCO2

Shunt fraction

Vd/Vt

GASTROINTESTINAL

Celiac blood flow

SMA blood flow

Mucosal blood flow

pHi

RENAL

Urinary output

Renal blood flow

GFR

HEPATIC

Portal blood flow

Mitochondrial function

Lactate clearance

ABDOMINAL WALL

Compliance

Rectus sheath blood flow


50 mL of sterile saline is instilled into the bladder via the aspiration port of the Foley catheter with the drainage tube clamped.

An 18-gauge needle attached to a pressure transducer is then inserted in the aspiration port, and the pressure is measured. The transducer should be zeroed at the level of the pubic symphysis.


MANAGEMENT

GRADING OF ABDOMINAL COMPARTMENT SYNDROME

GradePressure

(mmHg)Management

I 10-15 Maintenance of normovolemia

II 16-25 Volume administration

III 26-35 Decompression

IV >35 Re-exploration

Abdominal Perfusion Pressure (APP): APP = MAP - IAP

In one retrospective study, the inability to maintain an APP

above 50 mmHg predicted mortality with greater sensitivity

and specificity than either IAP or MAP alone .


OPERATIVE DECOMPRESSION

Vacuum-assisted

temporary abdominal

closure device:

Thin plastic sheet, a

sterile towel, closed

suction drains, and a

large adherent

operative drape. This

dressing system

permits increases in

intra-abdominal

volume, without a

dramatic elevation in

IAP.


ACS is a clinical entity caused by an acute, progressive increase in IAP.

Multiple organ systems are affected, usually in a graded fashion.

The gut is the organ most sensitive to IAH.

Treatment involves expedient decompression of the abdomen.

Pt already physiologically compromised Keep high degree of suspicion and a low threshold for checking bladder pressures to prevent the associated mortality

SUMMARY

References

ATLS Manual 9th Ed

Schwartz Principles of Surgery, 10th Ed

Sabiston Textbook of Surgery, 20th Ed

Manual of Trauma Surgery, Dept of

Surgery, AFMC, 2013

Trauma, Moore, 6th Ed

77

blunt trauma abdomen ankit

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