Abdominal trauma and assessment with primary and secondary survey. pptx

This is a great lecture on abdominal trauma, for medical students and newly graduated doctors.

1. ABDOMINAL TRAUMA : AN OVERVIEW

2. Int r oducti o n Abdominal trauma is regularly encountered in the emergency /casualty department One of the leading cause of death and disability Identification of serious intra-abdominal injuries is often challenging Many injuries may not manifest during the initial assessment and treatment period

3. Blunt Abdominal Trauma Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/syste m ) Most commonly injured organs? - spleen > liver, intestine is the most likely hollow viscus. Most common causes? - MVA (50 - 75% of cases) > blows to abdomen (15%) > falls (6 - 9%) Penetrating Abdominal Trauma Stabbing 3x more common than firearm wounds Gun shot wound cause 90% of the deaths Most commonly injured organs? - small intestine > colon > liver Pathophysiology of injury

4. Penetrating Abdominal Trauma Stab Wounds Knives, ice picks, pens, coat hangers, broken bottles Liver, small bowel, spleen Gunshot wounds small bowel, colon and liver Often multiple organ injuries, bowel perforations Pathophysiology of injury

5. Iatrogenic injury -En d os c o p ic /Lap a ros c o p ic s u r gic a l procedures -Inadvertent esophageal intubation -External cardiac compressions -Heimlich manoeuvre Pathophysiology of injury

6. Penetrating Trauma Penetrating abdominal trauma has a slightly higher mortality rate Second most common cause of abdominal injury

7. Gunshot Injury

8. Prehospital Care The goal of prehospital is to deliver the pt to hospital for definitive care as rapidly as possible. „Scoop and Run‟ Maintain airway & start I V line Care of spinal cord Communicate to medical unit Rapid transport of patient to emergency/ trauma centre

9. Initial Assessment and Resuscitation Primary Survey –ATLS a pproach ABCDE pattern: A irway, B reathing, C irculation, D isability (neurologic status), and E xposure. A - intubation may be required if patient is shocked, hypotensive or unconscious or in need for ventilation. *with cervical precaution. B - watch for hemothorax in both blunt and penetrating thoracoabdominal injuries. C - start with 2 L crystalloid (If active bleeding you must find source and stop the bleeding) D – M a y se e n as s oci at ed w i th tho r o c olu m ba r # E - W at ch f o r othe r inj ur y

10. Emergency Care I V fluids Control external bleeding Protect eviscerated organs with a sterile dressing Stabilize an impaled object in place Give high flow oxygen Immobilize the patient with a fractured pelvis Keep the patient warm Analgesics

11. Secondary Survey Full History & Examination History obtained from patient,other passenger,police and emergency medial personnel Physical examination inspect abdomen for abrasion,contusion,laceration,penetrating wound,distention and evisceration of viscera Palpate for tenderness,guarding,rebound tenderness,gravid uterus Auscultate for presence/absence of bowel sound Assess pelvic stability

12. Physical examination Grey-Turner sign : bluid discoloration of lower flanks, lower back; associated with retroperitoneal bleeding of pancrease,kidney or pelvic fracture. Cullen sign : bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage. Kehr sign : shoulder pain while supine ;caused by diaphragmatic irritation(splenic injury, free air, intra-abdominal bleeding) Balance sign : dull percussion in LUQ.Sign of splenic injury; blood accumulation in subcapsular or extracapsular spleen In the trauma patient, a ‘normal’ physical exam of the abdomen doesn’t equate to much. You NEED to do further testing.

13. In v e s ti g a t i o ns FAST X-Ray Chest & Abdomen CT Scan Diagnostic Peritoneal Lavage Diagnostic Laparoscopy

14. Focused Asse s sment with Sonogr a p h y in Trauma (FAST) First used in 1996 Rapid , Accurate Sensitivity 86- 99% Can detect 100 mL of blood Cost effective Four different views- Pericardiac Perihepatic Perisplenic Peripelvic space Eliminates unnecessary CT scans Helps in management plan

15. Plain X-Ray Chest & Abdomen Pneumotharax, Haemothorax Free air under diaphragm Nasogastric tube, bowel loops in the chest Elevation of the both /Single diaphragm Lower Ribs # -Liver /Spleen Injury Ground Glass Appearance – Massive Hemope

16. Diagnostic Peritoneal Lavage Mostly superseded by fast for unstable pt and CT scan for stable pt,useful when when this are inappropriate or unavailable for the identification of the presence of intraperitoneal fluid . Aspiration of blood, GI content, bile, or feaces through the lavage catheter indicates laprotomy .

17. Diagnostic Peritoneal Lavage Indications Unexplained Shock Contraindications Clear indication for Explo r a t ory Lapa r oto m y Relative - Previous Expl. Laparotomy -Pregnancy -Obesity

18. CT Scan The investigation of choice in haemodynmically stable pt in whom there is no indcation of emergency laprotomy It provides detailed information relative to specific organ injury and its extent and may guide/inform conservative management .

19. CT Scan Contraindication: Clear indication for Laparotomy Haemodynamically Unstable Allergy to contrast media

20. DIAGNOSTIC LAPAROSCOPY Haemodynamically stable patients Inadequate/equivocal USG Mild hypotension or persistent tachycardia Persistent abdominal signs/symptoms It decreases non-therapeutic laparotomies Useful in penetrating injury Limitation :Retroperitoneal Injury .

21. Indication for resuscitative laprotomy Unresponsive hypotension despite adequate resuscitation and no other cause for bleeding found .

22. Indication for urgent laprotomy * blunt abdominal trauma with positive DPL or free blood on ultrasound and an unstable circultary status. *Blunt trauma with CT feature of solid organ injury not suitable for conservative management. * Clinical feature of peritonitis. *Evisceration *Any gunshot wound.

23. Solid Organ Injuries Grading of injured solid organs such as Spleen, Liver & Kidneys are on the basis of subcapsular hematoma ,capsular tear, parenchymal lacerations & avulsion of vascular pedicle Bleeds significantly and cause rapid blood loss Difficult to identify injury by physical exam Repeated assessment is required to make the diagnosis Slowly oozing blood into peritoneal cavity .

24. splenic injury Most common intra- abdominal organ to injured (40-55%) 20% of splenic injuries due to left lower rib fractures Commonly arterial hemorrhage Conservative management : -Hemodynamic stability Negative abdominal examination -Absence of contrast extravasation in CT Absence of other indication of Laprotomy -Grade 1to 3 (Subcapsular Hematoma ,Laceration <3 cm) Monitoring Serial abdo. Examinations & Haematocrit are essential Success rate of conservative m/m is >80%

25. Splenic Injuries Operative Management Ca p s u l a r tears (I ) - Co m p r essi o n & topi c al hae m o static agent Deep Laceration (II) - Horizontal mattress suture or Splenorrhaphy Major Laceration not involving hilum (IV)- Partial Splenectomy Hillar injury (V)–Total Splenectomy Grade I V - V : a l m o s t i n v a riab l y r e q u ire intervention Success rate of Splenic salvage procedure is 40-60% operative

26. Liver injury Liver is the largest organ in abdomen 2 nd most common organ injured (35- 45%) in BA T Driving and fighting responsible for 50% of deaths due to liver injury Usually venous bleeding 85% of a ll pat i ents with blunt hepat i c trauma are stable CT is the mainstay of diagnosis in stable pt.

27. Liver Injury 50% liver injury have stop bleeding spontaneously by the time of surgery Non Operative m/m Haemodynamically Stable No other intra-abdominal injury require surgery Hemoperitoneum <500 ml on CT Grade I-III(subcapsular & intr-perenchymal hematoma)

28. Liver Injury Operative m/m Packing - Bleeding can be stopped by packing of abdomen -Pack removed after 48 hr -haemostatic agents -34 % survival in packing only

29. Laceration: -Mesh hepatorrhaphy -Omental flap to cover the laceration - Debridement Lobar Resection Liver Transplantation Ligate or repair damaged blood vessels & bile duct Mortality of liver injury is 10% Liver Injury Operative Management(Contd.) Suturing: -Simple suture -Deep mattress suture

30. Panc r eatic Inju r y Rare 10-20% of all abdominal injury Crush , Direct blow to abdo & Seat belt injury Associated with abdo. Duodenal injury, Vascular injury & liver injury Diagnosis – Difficult, High index of suspicion CECT Scan is helpful Serum amylase is a poor indicator Usually diagnose on Laparotomy Distal Pancreatic injury - Distal resection Pancreaticojejunostomy – Injury to Ampulla of Vater, Head & Body of Pancreas

31. Renal Injury Clinically not suspected & frequently overlooked Mechanism : Blunt , Penetrating # lower ribs or spinous process, Crush abdominal Pelvic injury Direct blow to flank or back Fall MVA

32. Renal Injury Diagnosis History ,Clinical examination Presentation :Shock, hematuria & pain Urine: gross or microscopic hematuria

33. Renal Injury Diagnosis (contd.) 5.X-ray KUB IVP 6. US 7 .CT Scan abdomen The degree of hematuria may not predict the severity of renal injury

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35. Renal Injury . Classification of Injury Grade I : Contusion or Subcapsular Hematoma Grade II: Non Expanding Hematoma, <1 cm deep ,no extravasation Grade III: Laceration >1cm with urinary Extravasation Grade IV: Parenchymal Laceration deep to CM Junction Grade V: Renovascular injury

36. Management of Renal Injury About 85% of blunt renal trauma can be manage by conservatively Renal Contusion : Conservatively Renal exploration : Indication D e ep c o rtic o -m e dulla r y Lac e ration with extravasation Large perinephric Hematoma Renovascular injury Uncontrolled bleeding Befo r e Neph r ect o my ,C o ntralateral Kidney should be assessed

37. Diaphragmatic Injury Incidence -0.8%-1.6% in BTA High index of suspicion required , may be missed. 40 to 50% are diagnosed immediately Presentation may be delayed Imaging Nasogastric tube seen in the thorax Abdominal contents in the thorax Elevated hemidiaphragm (>4 cm Lt vs Rt) Distortion of diaphragmatic margin. Lt- 69% , Rt -24% B/L- 15%

38. Diaphragm Rupture /Hernia

39. Hollow Viscus Injuries Gastric Injury : Penetrating trauma MC Blunt tr au m a abdo m en 1% Causes Penetrating Injury -Crushing Against the Spine - CPR -Heimlich Maneuver Diagnosis : X-Ray chest & Abdomen CT scan Diagnostic Peritoneal Lavage During Surgical Exploration T/t : Expl. Laparotomy with Primary Repair

40. Hollow Viscus Injuries (Contd.) Duodenum Isolated Duodenum injury rare Incidence - 3-5% Cause :Penetrating injury: mc Steering wheel injury Assault Fall Associated with other intra-abdominal injury Diagnosis: Plan X-ray –Free air in abdomen -Intraoperative diagnosis Rx : Primary Repair 80% case Roux-en –Y duodenojejunostomy 20%

41. Hollow Viscus Injuries Small Intestine& Colonic Injuries Commonly Injured in Penetrating injury Blunt Trauma - Incidence 5% -20% Mechanism : -Crush Injury -At Fixed point DJ & IC Junction Rx : Exploratory Laprotomy

42. Bladder Injury Commonly in BA T 70% of bladder Injury are associated with pelvic fracture . Hematuria Type 1 .Extraperitoneal Rupture-by bony fragment 2 . Intraperitoneal Rupture- at dome when blow in distended bladder Diagnosis -1. Clinical 2. Cystography T/t 1. Intraperitoneal –trans-peritoneal - closure +SPC 2: Extraperitoneal Rupture : Foley‟s catheter -10 -14 days

43. Ureteral Injury Uncommon Mostly occur after penetrating trauma Associated with concomitant intra-abdominal or genitourinary injury Diagnosis -IVP -15-20% Retrograde ureteroscopy - At the time of Laparotomy Operative procedure Proximal & mid ureter -End to end Anastomosis over DJ Stent Distal –Ureteric Reimplantaion

44. Vascular Injury Incidence 5-10% Highly lethal. Associated with extremely rapid rates of blood loss Exposure is difficult in Laparotomy Initial Control by digital pressure Heparinized saline (50U/ml) injected in both end of vessel Rx Lateral suture ,End to end Anastomosis & Interposition graft Mortality rate is very high

45. Penetrating abdominal trauma Gunshot Stab wound

46. Penetrating Abdominal T rauma Patients with deep penetrating injuries always require surgery Common Organs –Small int.(29%) liver(28%) Colon(23%)

47. Penetrating Abdominal Trauma(Contd.) Multiple in 20% of cases Most stab wounds do not cause an intraperitoneal injury A complete Laparotomy is mandatory

48. Penetrating Abdominal Trauma(Contd.) Abdominal Evisceration

49. Pen e trating Abdominal T rauma(Contd.) Abdominal Evisceration Never try to replace organs Cover with moist gauze, then sterile dressing. Transport immediately

50. Gunshot Injury Handguns, Rifles, and Shotgun More dangerous than penetrating injury The 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 Distance . Injury multiple organ

51. Major complication of abdominal trauma

52. Abdominal Compartment Syndrome Common problem with abdominal trauma Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure ± APP bel o w 5 mm Hg Primary ACS: associated with injury/disease in abdomen Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak)

53. Effects of elevated IAP Renal dysfunction Decreased cardiac output Increased airway pressures and decreased compliance Visceral hypoperfusion

54. Management Surgical abdominal decompression Nonsurgical: paracentesis, NGT, sedation Staged approach to abdominal repair Temporary abdominal closure

55. Injury Prevention 1. Primary : Prevent an injury from its occurrence in the first place: Educational activity such as anti- drink-driving campaigns , speed limit rule -Children should accompanied with parent 2. Secondary : Attempts to lesson the consequences of injury – making road & safer car, anti-locking brakes, air bags , helmets, seat belt 3. T ert i ary : M i ni m ize the e f fect of i nju r y by heal t h care by individuals & system.

56. Injury Prevention (Contd.) Speed is a critical factor ; a 10% increase speed translate into a 40% rise in the case fatality rate. Use of seat belt reduces the risk of death or serious injury by 45%. Air Bags reduces the risk of fatal injury by 30% & deaths by 11 %. Children Below 12yrs should be properly restraints in the back seat. Motorcycle experience death rate 35 time greater than car.

57. Sum m ary Injuries are Preventable Trauma is a massive & growing health burden worldwide ,which increasingly afflicts the young & productive age group. Repeated assessment is required to make the diagnosis Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of Hemoperitoneum Conservative approach in Liver & Renal Injury Successful m/m of trauma requires integration of Prehospital ,in-hospital ,& rehabilitative care.