Abdominal Injuries Part 1.pptx

Presentation on the management of abdominal injuries including the causes of abdominal injuries; the classification of abdominal injuries; the initial management of patients with abdominal injuries according to the ATLS; trauma laparotomy

1. ABDOMINAL INJURIES PART 1 ( 16 th JANUARY 2023) Dr. M. Yigah

2. Introduction Trauma is the leading cause of death between ages 1 and 44 The abdomen is third most injured region of the body. Abdominal injuries accounts for 15 - 20% of all trauma deaths Abdominal trauma is traditionally classified as either blunt or penetrating. Morbidity and mortality from abdominal injuries are due haemorrhage and sepsis It is usually associated with injuries of other regions of the body. Missed or delayed diagnoses are the most common cause of death from these injuries

3. Epidemiology Epidemiology of abdominal injuries varies across the continent In Egypt it account for 82.7% of all trauma cases (Gad et al 2012) 14.2% of all trauma cases in Mbarara hospital in Uganda ( Ruhinda et al 2008) Ghana Ghana Medical Journal– 234 abdominal injuries were seen between 1983 and 1989 (Naaedar 1990) 411 patients were seen with penetrating injuries in KBTH and KATH between 1998 to 2008 ( Dakubo et al 2010) KBTH – General Surgery Logs 1772 cases in total were done between August and December 5 Trauma laparotomies Spleen was the most injured viscus – 3 cases Small bowel and mesenteric injuries – 2 cases

4. Boundaries of the Abdomen

5. Internal Abdomen

6. Classification of Abdominal Injuries Non-penetrating abdominal Injuries Damage to the abdomen and/or abdominal organs secondary to the impact of blunt forces applied across an abdominal region. Forces can be localised to one region of the body or across a wide area. Penetrating abdominal Injuries Occurs when there is a full thickness violation of the abdominal wall which may or may not be associated with visceral injuries. Visceral injury is more likely when the fascia is breached. Often limited to a localised region of the abdomen [exception of blast injuries]

7. Blunt Injuries Automobile accidents Fall from heights Impalement of blunt objects Assaults – kicks and blows Blast injuries Sports injury Penetrating Injuries Stab wound Gunshot wound RTA Impalement of sharp objects Flying objects Falls from height

8. Frequency of Injured Organs Blunt Injuries Spleen – 26% Kidney – 24% Intestines – 16% Liver – 16% Other – 20% Penetrating Injuries Stab wounds Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) Gunshot wounds Small bowel (50%) Colon (40%) Liver (30%) Abdominal vascular structures 25%

9. Mechanisms of Abdominal Injuries Blunt Abdominal Injuries Deceleration forces – generates shearing forces that avulse structure near fix points Crushing forces – compression of visceral between abdominal wall and vertebrae Blow-out forces – sudden increase in intra-luminal pressures cause hollow viscus to rupture Penetrating Abdominal Injuries Construction of injuring agent – e.g., length of knife, calibre of bullet. Energy behind injury – e.g., stabbing forces vs gunshots.

10. Pathophysiology Haemorrhage Injury to solid viscera – early death if not managed efficiently Injury to major abdominal vessel – immediate death Sepsis Spillage hollow viscus contents - chemical and bacterial peritonitis. Death is usually slow.

11. ATLS Protocol Primary survey Airway and Cervical spine control Breathing Circulation and Control of Haemorrhage Assessment of level of consciousness, Pulse rate and Volume, BP, Skin perfusion Identify any source of external or internal bleeding Venous access with 2 wide bore cannulae Samples for baseline investigations – FBC, GXM, Clotting profile, Serum Lactate, Serum Amylase, Administration of warmed crystalloids, blood and plasma Disability – assessing level of consciousness, Exposure and Environmental Control Adjuncts of Primary Survey ECG, Pulse Oximetry, ABG, NG tube, Urinary Catheter, Chest X-ray, Cervical and Pelvic X-ray FAST, eFAST, DPL

12. Categorization of Patients Haemodynamically ‘normal’ investigation can be completed before treatment is planned; Haemodynamically ‘stable’ – Investigation is more limited. It is aimed at establishing whether the patient can be managed non-operatively, whether angioembolization can be used or whether surgery is required; Haemodynamically ‘unstable’ – Investigations need to be suspended as immediate surgical correction of the bleeding is required.

13. ATLS Protocol Secondary Survey Short Concise Relevant History (AMPLE) Allergies Medications currently used Past illnesses/Pregnancy Last meal Events/Environment related to the injury Speed and Type of collision (frontal, lateral, sideswipe, rear, rollover) Types of restraints Patient's position in vehicle Fatalities at scene Height of fall Type of gun or knife used Physical Examination Head to toe

14. Evidence of Abdominal Injuries Obvious penetrating instrument Evisceration of bowel, omentum etc. Ecchymosis on abdominal wall: Grey-Turner sign, Cullen sign, Seatbelt sign Peritonism Tenderness, guarding and Rebound tenderness BS may be abolished Tenderness on DRE Balance sign – Dull percussion in the LUQ (Blood in subcapsular or extracapsular spleen) Kehr sign - Left shoulder pain while supine; caused by diaphragmatic irritation

15. Cullen’s Sign Evisceration of Intra-abdominal Organs Seatbelt Sign Grey-Turner Sign Penetrating Agents

16. Investigations Baseline labs FBC Grouping and Cross matching. Coagulation profile, ß-HCG, Amylase X-rays - Chest, Cervical and Pelvic x-ray It should not delay in resuscitation Chest x-rays can show potentially life-threatening injuries Pelvic X-ray – fracture responsible for haemoperitoneum Abdominal X-ray – Has been superseded by FAST Can demonstrate trajectory of penetrating agent

17. FAST Focused Assessment with Sonography for Trauma Blood in the pericardial sac, hepatorenal fossa, splenorenal and POD . Not to assess visceral injury A positive FAST and Haemodynamically unstable patient is an indication for Exploratory Laparotomy

18. Diagnostic Peritoneal Lavage To detect haemorrhage, bowel and biliary contents in unstable patients Abdominal evaluation in stable patients in settings where FAST and CT are not available . Relative contraindications previous abdominal operations, morbid obesity, advanced cirrhosis preexisting coagulopathy

19. Positive DPL Aspiration of 10ml or more of free blood. RBC of >100000/ml. Aspiration of GIT contents, vegetable fibers, or bile. WBC >500/ml Amylase > 19 IU/L Alkaline phosphatase > 12IU/L Bilirubin level - > 0.01mg/dL

20. CT Scan Gold standard for evaluating solid organ blunt abdominal injury. It is however time-consuming and requires a co-operative patient. Used only in hemodynamically normal patients in whom there is no apparent indication for an emergency laparotomy Can be used to used to detect and grade solid organ injuries (Based on the AAST) Help quantify the volume of intra-peritoneal haemorrhage Used to assess retroperitoneal and pelvic organ injuries

21. Selective Angiography

22. Laparoscopy To be done in stable patients only Applications Screening: to exclude a penetrating injury with breach of the peritoneum. Diagnostic: finding evidence of injury to viscera. Therapeutic: used to repair the injury Still not fully developed

23. Indications for Exploratory Laparotomy Blunt abdominal trauma with hypotension with positive FAST or clinical evidence of intraperitoneal bleeding, or without another source of bleeding Hypotension with an abdominal wound that penetrates the anterior fascia Gunshot wounds that traverse the peritoneal cavity Evisceration Peritonitis Free air, retroperitoneal air, or rupture of the hemidiaphragm Contrast-enhanced CT that demonstrates Ruptured gastrointestinal tract, renal pedicle injury, or Severe visceral parenchymal injury after blunt or penetrating trauma Blunt or penetrating abdominal trauma with positive DPL

24. Trauma Laparotomy Team Preparation Assemble and coordinate the operating team : Notify the emergency scrub team to create theatre space, prepare equipment and call other colleagues. Inform the anesthetic team Ensures there is an understanding of the available equipment and definition of role Discussion of injury burden, time frame if getting knife to skin and agree on definitive vs DCS goals. Request for likely equipment one will need An open vascular set with vascular clamps Multiple large abdominal swabs Bowel stapler Self-retainer retractors if the patient is obese Long needle holders with desired sutures Cell saver suction device An energy device such as a Harmonic scalpel or LigaSureTM . Inform the ICU team to make a bed available

25. Trauma Laparotomy Perioperative preparation 2 large bore venous access Foleys catheter and an NG tube passed Blood products should be obtained Temperature control of the room and the patient Administration of perioperative antibiotics Positioning and skin preparation Supine position with arms fully abducted at 90 o Skin is prepared from the chin to the knees and between the posterior axillary lines Draped from chine to above the knee (risk of hypothermia)

26. Operative Sequence

27. Trauma Laparotomy Abdominal access Bold midline incision from xiphisternum to pubis. Use the scalpel (diathermy is time consuming) Divide the falciform ligament if necessary. Use a virgin territory if there are previous scars Complete evisceration of small bowel Securing haemostasis Evacuate the liquid and clotted blood from all 4 quadrants Deliver the small bowel in two large abdominal packs to the patients right Systematically empirical pack the abdomen – Liver, Right Paracolic gutter, Spleen and Left paracolic gutters and pelvis Inspection and clamping of any bleeding mesenteric vessels. Aortic clamping – in rapidly exsanguinating patients

28. Packing of Abdomen

29. Trauma Laparotomy Exploring the abdomen Run the gut from the ligament of Treitz to the rectum Systematically remove the pack around the liver and asses its injuries. Assess the gallbladder and the biliary tree Palpate the right kidney Carefully Inspect the spleen after removing the pack Palpate the left kidney Inspect the hemi-diaphragms Enter and inspect the lesser sac through the left side of the greater omentum. Mattox manoeuvre or Cattell– Braasch maneuver

30. (Cattell- Braasch manoeuvre) (Mattox manoeuvre )

31. Trauma Laparotomy Choosing an operative profile Definitive repair of the injuries with formal abdominal closure Damage Control techniques and temporary abdominal closure Factors to consider Pattern of injury – e.g., major vascular injury – definitive repair but a hollow viscus injury – DCS Overall trauma burden e.g., serious injury to another region (head injury) Operating room system and circumstances - small rural facility, limited trauma experience etc. Physiological insult Duration of hypotension, Realistic estimate of blood loss and transfusion requirements Onset of metabolic acidosis (pH< 7.3) and hypothermia – late indicators Subtle perceptual clues Initially start definitive repair but conditions changes – e.g. oedema of bowel wall, touch, diffuse oozing of blood

32. Damage Control Surgery Principles of DCS Control of bleeding Identification of injury Control of contamination Protection from further injury e.g., abdominal compartment syndrome

33. Trauma Laparotomy Abdominal Wound Closure Definitive Repair – Standard closure as with Laparotomy Dictated by level of contamination of wound Damage Control Surgery (DCS) – Closure is temporary with 4 objective Containment of viscera, Control of abdominal secretion, Maintenance of pressure on tamponaded areas, and Optimization of the likelihood of eventual closure Techniques – Running sutures, Bogota bag, towel clips, Ioban , Vacuum closures

34. Management after DCS Continued resuscitation and restoration of normal physiology Reversal of Hypothermia Nurse patient in a warm room, Administer warm intravenous fluid and blood products, Application of external warming devices (Bair Hugger). Reversal of acidosis Correction of shock will correct metabolic acidosis Patient’s ability to normalize lactate is strongly correlated with survival Correction of Coagulopathy Correction of acidosis and hypothermia corrects it Replacement of blood products Recent – use of recombinant factor VIIa

35. Abdominal Compartment Syndrome Causes bowel wall oedema Third space fluid loss Intra-abdominal packing Diagnosis Intra-vesical pressure with foleys catheter connected to a transducer or manometer Treatment Management is dependent of pressure levels 10-15cm/H2O Maintain euvolaemia 16-25cm/ H2O Hypervolaemic resuscitation 26-35cm/H2O Decompress > 35cm/ H2O Decompress/re-explore abdomen looking for bleeding

36. Reoperation after DCS Should be done within 48 – 72hrs before the onset of SIRS It involves Removal of abdominal packs Confirming haemostasis Inspection of abdomen for any missed injuries Restoration of intestinal integrity and abdominal wound closure.

37. END OF PART 1