AAST grading - Bowel/Intestinal Injury

The Americal Association for the Surgery of Trauma - guidelines for intestinal injury- grading and a brief description of duodenal injury and few Most common Questions

1. You may forget her, but she will never forget you Intestine

2. AAST Grading of Bowel Injury Evidence based FAQs Dr Awaneesh Katiyar Senior Resident Trauma Surgery and Critical Care AIIMS Rishikesh 

3. Overview Introduction Mechanism and initial management Grading of bowel injury Duodenal injury -brief management Topic of Discussion - related articles

4. Introduction 11% - blunt abdominal trauma - bowel perforation 5-15% in in various articles 3rd most common organ injured Most common - cause of sepsis related deaths Zarour A, El-Menyar A, Khattabi M, Tayyem R, Hamed O, Mahmood I, Abdelrahman H, Chiu W, Al-Thani H. A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients. International Journal of Surgery. 2014 Apr 1;12(4):340-5.

5. Evaluation and Management Bowel trauma - Mechanism RTA - seat belt, steering wheel, crash Direct Kick to abdomen - physical assault Fall of object over abdomen Penetrating injury - gunshot, impalement, stabs Animal attack Workplace related - suspension or reverse suspension

6. Initial Assessment and Plan ATLS protocol A-B-C-D-E: Key to success Decision - stable or unstable - Exploratory Laparotomy or Damage control Addressing - shock - critically important Isolated to concomitant injuries Worse prognosis - concomitant Isolated Mesenteric injuries Dealing with duodenal trauma

7. Manegement strategies Unstable patient Control haemorrhage - continue resuscitation Control contamination - 2nd option Divert the bowel - stoma Duodenum - unique Doubt - consider on worst side - do on best side

8. Manegement strategies Stable patient Mechanism - clue to site of injury Esophagus - penetrating >>> blunt Stomach - penetrating Small bowel - blunt >>> penetrating Duodenum - seat belt, steering wheel , direct blow , penetrating Large bowel - blunt > penetrating Rectal - penetrating - rectum impalement injuries

9. Examination External patter of injury - direct hint

10. AAST classification

11. Highest mortality 25cm - 4 parts 3-5% - blunt abdominal trauma Isolated injury - uncommon Pancreas, IVC and aorta 2nd part - most commonly injured Penetrating (78%) blunt (22%) Duodenal injury

12. Specific cases - steering wheel or direct epigastric blow Severe abdominal pain Out of proportion - pancreas associated Vomiting, retching with blood Nothing is accurate - diagnosis High index of suspicion History & Examination

13. Abdominal x rays - not useful for diagnosis USG - not diagnostic - raised high index of suspicion CT scan - always recommend CT miss perforation up to 28-30% DPL unreliable - 40% Radiology

14. Mild to moderate Stab wound 75% wall 3rd and 4th < 24 hours No Associated bile duct injury Severe injury Blunt or missile injury More than 75% 1st & 2nd part injured > 24 hours Associated with bile duct injury Severity of injury

15. Principles Restoration gut continuity Decompression of duodenal lumen Provide external drainage Provide Nutritional support Management

16. Topic of debate ? management of Bowel injury

17. Are we missing bowel injury? Present - late - Traumatic bowel - mesenteric injury Clinical diagnostic - dilema CT scan - no sign of perforation USG - no conclusive 1% of all bowel injuries - mesenteric injury leading to bowel necrosis High index of suspicion Review CT - signs ischemia or Necrosis > 8 hr - associated with significant mortality - sepsis

18. Do we go for definitive surgery in 1st step? Even if patient is stable- Decision for definitive surgery - better other than duodenal trauma Duodenum - high pressure zone Complication or leak - higher > Grade 4 trauma Principle of Duodenum management should always be followed

19. Should be do single step surgery ?

20. Single layer or Double layer ? Standard practice - depends on surgeon choice Esophagus - single layer Stomach and small Bowel - Double layer Large bowel - single player Doudenum - single layer Emergency - Single layer is better

21. Single layer or Double layer Journal of Clinical and Diagnostic Research. 2017 Jun, Vol-11(6): PC01-PC04 Equally Effective And More cost effective

22. Stoma or Anastomosis ? Patient condition Hemodynamics - unstable Investigation - Hb , Alb, Lactate, Vasopressor - high dose Performing DCS Perineum wound, distal anastomosis Live Problems are better than dead solutions

23. Do we have better grades for bowel injury ? AAST best - adopted grading even for Bowel injury - Management Z score blunt trauma - non Validated Based on clinical , USG and CT findings Used for early Diagnosis

24. PATI Penetrating Abdominal trauma Index Not Widely Accepted Only used in penetrating trauma

25. Diagnostic Lap in Blunt Trauma ? Blunt or Penetrating Conclusion - laparoscopy in stable blunt abdominal trauma is safe and feasible, with expert hand. Avoid laparotomies and reduces LOS. Journal of Surgical research, Australia

26. Occult Bowel Injury(CT) Free fluid without SOI Visceral Adhesions Independent Predictors

27. Thank you You may forget her, but she will never forget you Intestine