Abdominal Trauma Call Management Approach.pptx

Approaching and management of patients with abdominal trauma/ injury

1.  ABDOMINAL TRAUMA CALL KIRENGO ST3 YGC GEN SURG MBChB, MBA, MSc, MRCS(Ed)

2. OBJECTIVE:

3. INTRODUCTION: Incidence <10% all Trauma Abdominal injuries occur in 1/3 of patients with Severe Trauma Most common injuries affect: Liver, Spleen, Kidneys Mortality in up to 20% of trauma laparotomy Mechanism: Blunt or Penetrating Abdo assessed in Circulation in ATLS Primary survey Abdominal & pelvic injuries may be missed/ unrecognized ETOH/ intoxication, brain or spine injury, adjacent injuries (chest), retroperitoneal injury Significant blood loss w/o external signs

4. ANATOMY:

5. MECHANISMS OF INJURY:

6. ASSESSMENT:

7. EMERGENCY RESUSCITATION: IV Fluids- 1L Bolus crystalloid Blood transfusion – if unresponsive to IVI Control external bleeding Dressing wounds & eviscerated organs High-flow O 2 Patient warming Analgesia Immobilization/ pelvic binding Antibiotics *Tranexamic acid

8. Hx:

9. PHYSICAL EXAM:

10. CLINICAL SIGNS: Seat Belt sign: Bruising or ecchymosis around skin on seatbelt distribution Intra-abdominal injury- bowel, mesentery, solid organs Cullen’s sign: Bluish discolouration around umbilicus Blood in periumbilical tissues or falciform Hemoperitoneum, Retroperitoneal bleed, *severe pancreatitis Grey-turner’s sign: Bluish discolouration in flanks Retroperitoneal hematoma/ *hemorrhagic pancreatitis Kehr’s sign: Referred pain to Lt shoulder – diaphragmatic/ phrenic irritation (C3-5) Splenic rupture, Pneumoperitoneum, hemoperitoneum Balance sign: Dullness on percussion of LUQ Ruptured spleen

11. ADJUNCTS: Gastric tube insertion Urinary catheter FAST- *risk of false negative, >100mls blood/fluid CXR: exclude hemo /pneumothorax in penetrating injury above umbilicus, air under diaphragm CT scan

12. MANAGEMENT: Non-operative management Serial physical examination – 94% accuracy Serial Hct / Hb CT-scan IR – Liver, spleen, pelvis (contraindicated in hemodynamically unstable) Diagnostic laparoscopy Laparotomy: Blunt abd trauma + hypotension + evidence of intraperitoneal bleeding Penetrating abd trauma + hypotension/ or GI or GU tract bleeding Gunshot to abd Evisceration Peritonitis CT evidence of injury needing surgical intervention

13. GOAL OF LAPAROTOMY: Damage control surgery: Focus on restoration of physiology/ function Trauma triad of death: hypothermia, acidosis, coagulopathy Deferred definitive treatment Temporary abd closure Haemorrhage control Contamination control Definitive treatment + Anatomical repair

14. PELVIC INJURY: Hypotension + pelvic injury assoc with high mortality (upto 42%) Pelvic fracture: AP Compression Lateral Compression Vertical Shear Management: Hemorrhage control Fluid/ Blood resuscitation Pelvic stabilization - binders

15. CASE 1:  B4521161 55M TRAUMA CALL TO ED Ambulance referral with self stab to abdomen Found covered in blood waist down, knife 4-5 cm long, 3cm laceration Bleeding had stopped Obs: A- clear, B- elevated RR, Sats-95%, C- HR -98, weak radial pulse, BP-67/37, CR 4sec D- GCS-14 Done: Bilat cannulation, fluids (saline), Tranexamic 1gm, O2-100% nasal cannula, ,  Bloods: Hb-134 (150s), Plt-375, Hct-0.41, Cr-256, Ur-7.7, eGFR-23 (>90)

16. PLAN:

17. CT IMAGES:

18. CT-ABD PELVIS: Conclusion: 1. Superficial penetrating injury supraumbilical abdominal wall. 2. No significant intra-abdominal trauma evident. 3. Incidental right renal cortical mass, suspicious of a T1b RCC. 4. No regional nodal or metastatic disease. 5. Small left lower pole renal calculus. 6. Minor basal atelectasis. 7. Small periumbilical abdominal wall hernia. -Suggest urology referral in due course.

19. CASE 2:  G338175 97M Unwitnessed fall, long lie, coffee ground vomitus on side SH: care home, dementia, AF (on DOAC) Obs: R-18, Sat-98%, P-63, CR <2Sec, BP-113/ 62 (86/60), HR-84 irregular AF, GCS-14 Hx: Not forthcoming, some abd pain Bloods: WCC-14, Hb-142, Neu- 12.2, Leu-0.9, Lact- 5.0, CRP-12, Ur-9.0, Cr-136, eGFR-42(47)

20. CT IMAGES:

21. CT TRAUMA: Head:  Old right parietal temporal infarct. Left frontal lobe hypoattenuation, more prominent than previous (CT 16/03/2024) -likely representing a matured area of infarction. No intracranial haemorrhage, new cortical infarction or mass lesion. Neck: No injury Thorax: No injury Abd/ Pelvis: Full-thickness laceration of the inferior pole of the spleen not involving the splenic hilum. Associated perisplenic haematoma extending into the left paracolic gutter.

22. PLAN:

23. SUMMARY:

24. QUESTIONS?

25. REFERENCES: Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality pattern. Wiik Larsen, Johannes et al.Injury , Volume 53, Issue 10, 3130 – 3138 Marsden, Max E.R. MBBSa,b,c ,*; Vulliamy , Paul E.D. MBBS, PhDa,b ; Carden, Rich MB, ChB, MSca,b ; Naumann, David N. MB, BChir , PhDc,d ; Davenport, Ross A. PhD, FRCSa,b  for the National Trauma Research and Innovation Collaborative ( NaTRIC ). Trauma Laparotomy in the UK: A Prospective National Service Evaluation. Journal of the American College of Surgeons 233(3):p 383-394,394e1, September 2021. | DOI: 10.1016/j.jamcollsurg.2021.04.031 ATLS 10 TH Edition