Blunt abdominal trauma.ppt0021.pptx

Blunt trauma

1. Blunt abdominal trauma Dr Mohan Reddy

2. Spleen is the most common organ involved in blunt trauma. Often in blunt trauma first part of the jejunum or ileocaecal junction gives way ( blow out effect) due to traction often causing complete transection of bowel horizontally close to the junction. It is due to force of the mobile part of the bowel over the fixed part.

3. Abrasion over the abdominal skin suggests the possibility of internal injury (London’s sign).

4. Mechanism of Injury: Blunt C ompression, crush, or sheer injury to abdominal viscera: deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus) Deceleration injuries: differential movements of fixed and non-fixed structures (e.g. liver and spleen laceration at sites of supporting ligaments)

5. Pattern of Injury in Blunt Abdominal Trauma Spleen 40.6% Colorectal 3.5% Liver 18.9% Diaphragm 3.1% Retroperitoneum 9.3% Pancreas 1.6% Small Bowel 7.2% Duodenum 1.4% Kidneys 6.3% Stomach 1.3% Bladder 5.7% Biliary Tract 1.1%

6. General Clinical Features Features of shock—pallor, tachycardia, hypotension, cold periphery, sweating, oliguria. Abdominal distension. Pain, tenderness, rebound tenderness, guarding and rigidity, dullness in the flank on percussion. Respiratory distress, cyanosis depending on the amount of blood loss. Bruising over the skin of the abdominal wall. Features specific of individual organ injuries.

7. Diagnostic Peritoneal Lavage Introduced by Root (1965) Today DPL is performed less frequently, as it has been replaced by focused abdominal sonography for trauma (FAST) and helical computed tomography (CT). DPL is the only invasive test of the three, but while lacking organ specificity it remains the most sensitive test for mesenteric and hollow viscus injuries 

8. Indications for DPL in blunt trauma Hypotension with evidence of abdominal injury Multiple injuries and unexplained shock Potential abdominal injury in patients who are unconscious , intoxicated , or paraplegic Equivocal physical findings in patients who have sustained high - energy forces

9. Contraindications of DPL Absolute  : Peritonitis Injured diaphragm Extraluminal air by x-ray Significant intraabdominal injury by CT scan Intraperitoneal perforation of the bladder by cystography Relative : Previous abdominal operations ( because of adhesions ) Morbid obesity Gravid Uterus Advanced cirrhosis ( because of portal hypertension and the risk of bleeding ) Preexisting coagulopathy

10. DPL: Procedure

11. 3 methods of introducing DPL catheter 1.closed approach(seldinger) –uncontrolled depth of penetration. 2.Open procedure-safer but time consuming,introduces air into peritoneal cavity. 3.semiopen technique(at infra umbilical region)-prefered,quick,easy,reliable.

12. Preferred Site of Diagnostic Peritoneal Lavage Standard adult :Infraumbilical midline Standard pediatric: Infraumbilical midline 2ed &3ed trimester pregnancy :Suprauterine Midline scarring :Left lower quadrant Pelvic fracture: Supraumbilical

13. Evaluation of DPL Fluid is sent for: cell count, amylase, alk phos, presence of bile Index Positive value Aspirate Blood >10 mL Fluid Enteric content Lavage RBC > 100,000/mL WBC > 500/mL Amylase >175 U/dL Alk Phos > 3 IU Bile Confirmed Negative RBC < 50,000/mL WBC < 100/mL Amylase < 75 U/dL

14. Diagnostic Peritoneal Lavage RBC Count Incidence of visceral damage >100,000 95% 20,000-100,000 15-25% Warrant further investigation <20,000 < 5% Complications of DPL: Perforation of small bowel, mesentery, bladder and retroperitoneal vascular structures. Limitation: offers no information about status of retroperitoneal organs nor allow determination of which organ has been injured.

15. FAST(Focused Abdominal Sonography for Trauma) : Strengths and Limitations Strengths Rapid (~2 mins) Portable Inexpensive Can be performed serially Useful for guiding triage decisions in trauma patients Limitations Does not typically identify source of bleeding, Requires extensive training to assess parenchyma reliably Limited in detecting <250 cc intraperitoneal fluid Particularly poor at detecting bowel and mesentery damage (44% sensitivity) Difficult to assess retro peritoneum Limited by habitus in obese patients

16. FAST Four View Technique: Morrison’s pouch (hepatorenal) Douglas pouch (retropelvic) Left upper quadrant (splenic view) Epigastric (View pericardium)

17. Morrison’s pouch (hepato-renal space) Douglas pouch (retropelvic)

18. Left upper quadrant (splenic view) Epigastric (View pericardium)

19. FAST: Accuracy For identifying hemoperitoneum in blunt abdominal trauma: Sensitivity 76 - 90% Specificity 95 - 100% The larger the hemoperitoneum, the higher the sensitivity. So sensitivity increases for clinically significant hemoperitoneum. FAST can detect? 250 cc total 100 cc in Morison’s pouch

20. FAST and CT CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. The gold standard for characterizing intraparenchymal injury. “Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be performed during resuscitation.

21. Evaluation Blunt trauma patients who are unstable and have intra-abdominal fluid identified on FAST require an emergent laparotomy to manage bleeding. If FAST is unavailable, aspiration of 10 mL or more of gross blood on DPL also suggests an intra-abdominal source of hemorrhage requiring emergent operation. Furthermore, patients with peritonitis require abdominal exploration to evaluate for hollow visceral injury. Other patients will undergo further workup of the abdomen to evaluate for intra-abdominal injury.

22. Abdominal CT The mainstay of imaging for the stable blunt trauma Has led to the emergence of nonoperative management of many solid abdominal organ injuries. Performed with IV contrast timed to capture the portal venous phase, which best demonstrates the vasculature and visceral perfusion of the solid abdominal organs.

23. Excellent visualization of the solid organs, allowing the characterization of injury severity (injury grade) and the recognition of active bleeding, which appears as contrast extravasation. Imaging findings assist in making management decisions regarding the need for operative, nonoperative, or angiographic therapy

24. The retroperitoneal structures are also well visualized on CT, identifying injuries that are difficult to evaluate with FAST or DPL.

25. DPL demonstrating more than 100,000 red blood cells/mm3 is indicative of intra-abdominal injury and historically mandated a laparotomy . The high nontherapeutic laparotomy rate associated with this practice has led to the nonoperative principles commonly used today because a large percentage of abdominal structures that had bled were no longer bleeding at the time of abdominal exploration. The frequent lack of bleeding at laparotomy suggested that the patient’s physiologic condition was more important than the presence of intra-abdominal blood when making treatment decisions.

26. Abdominal CT is less sensitive for detecting hollow visceral injury. Hollow viscous injury is suggested by the recognition of bowel wall thickening, inflammation in the surrounding adipose tissue seen as stranding, or presence of free intraperitoneal fluid. Administration of oral contrast is not necessary and might increase the risk of vomiting with aspiration. It is paramount that the presence of unexplained free fluid on imaging be carefully evaluated and a high index of suspicion for bowel injury be maintained.

27. Frequently, a combination of these radiographic findings, with clinical signs and symptoms such as an abdominal seatbelt mark or tenderness on examination, are suggestive and may require exploration. A challenging scenario is the identification of intra-abdominal fluid on imaging without the presence of solid organ injury to explain its presence.

28. In a significant percentage of cases, this fluid represents blood from a mesenteric tear Fluid visualized in more than one abdominal quadrant suggestive of a bowel injury requiring laparotomy.

29. SPLENIC INJURY Splenic injury occurs commonly following road traffic accidents, other blunt injury or penetrating/stab injuries. Most often associated with fracture of left lower ribs, haemothorax, injury of liver (left lobe commonly, occasionally both lobes), bowel, tail of pancreas, left kidney. Injury is more common and severe in enlarged spleen, i.e. in malaria, tropical splenomegaly, infectious mononucleosis. Spleen is the most common solid organ injured in blunt abdominal trauma.

30. Types of Injury Splenic subcapsular haematoma : After initial injury patient remains asymptomatic for a short period. But this haematoma ruptures later causing torrential haemorrhage . Clean incised wound over the surface Lacerated wound. Splenic hilar injury causes torrential haemorrhage , may even cause death. So immediate surgical intervention and splenectomy is done. Splenic injury associated with other injuries (left kidney, left colon, small bowel, pancreas, diaphragm, left lung).

31. Presentation Features of shock: tachycardia, hypotension, fever, restlessness, pallor. Hemoperitoneum: abdominal distension. Diffuse abdominal tenderness, localised guarding in the left upper quadrant. Death sometimes.

32. Dullness in the left flank which does not shift, as the collected blood gets clotted. Dullness without shifting— Ballance’s sign. Clot collected under the left side of the diaphragm irritates it and the phrenic nerve causing refered pain in the left shoulder— Kehr’s sign. There may be left sided haemothorax with fracture of ribs.

33. Delayed presentation is also possible due to formation of subcapsular haematoma which later gives way. Initially gets temporarily localized by greater omentum, later giving way leading to torrential bleeding. Blood clot temporarily seals off the bleeding which later gets dislodged causing severe bleeding. This time period in between is called ‘ latent period of Bandet’.

34. Investigations U/S abdomen is the investigation of choice Hb%, PCV, blood grouping and cross matching. Adequate amount of blood must be kept ready for transfusion. CT scan will show type of splenic injury and its class.

35. Plain X-ray abdomen findings Obliteration of splenic outline Obliterarion of psoas shadow (most important feature) Indentation of fundic gas shadow Fracture of lower ribs Elevation of left side of diaphragm Free fl uid in the abdomen between coils of intestine

36. CT findings  Three CT findings correlate with the need for intervention: Devascularization or laceration involving 50% or more of the splenic parenchyma Contrast blush greater than one centimeter in diameter (from active extravasation of IV contrast or pseudoaneurysm formation A large hemoperitoneum.

37. Contrast-enhanced CT scan : sub capsular splenic hematoma that involves more than 50%

38. CT shows a subcapsular hematoma with a splenic laceration extending from the capsule to the hilum with an intraparenchymal hematoma (blue arrow).  Within the intraparenchymal and subcapsular hematomas are areas of hyperdensity that represent active extravasation (red arrow).

39. Complications of Splenic Rupture/Trauma Blood loss. DIC. Sepsis. Splenic artery pseudoaneurysm. Splenic arteriovenous fi stula. Problems of associated injuries like of pancreas.

40. Grade of Splenic Injury I Hematoma subcapsular, <10% Laceration < 1cm deep II Hematoma subcapsular, 10-50% intraparenchymal, <5 cm Laceration 1-3 cm deep III Hematoma >50%, ruptured, >5cm Laceration >3 cm, + trabecular vessels IV Laceration segmental or hilar vessel with major devascularisation V Laceration shattered spleen, avulsion

41. Classic criteria for non operative management Hemodynamic stability Negative abdominal examination Absence of contrast extravasation on CT Grade 1 injuries Grade 2 injuries Grade 3 injuries that are isolated

42. Criteria for operative management of splenic injury Grade IV and V injuries Instability at admission, when the exact location of bleeding is unknown After failed nonoperative management

43. OPERATIVE MANAGEMENT Capsular tear-compression/haemostatic agents Deeper lacerations-absorbable mattress sutures Major lacerations involving <50% of parenchyma and not extending into hilum-segmental/partial splenectomy Extensive injury involving hilum or central portion of spleen-splenectomy

44. A more recent advance in the management of splenic injury has been the use of angiography Angiography can identify specific sites of bleeding from the splenic parenchyma and underlying segmental or trabecular vessels One major benefit of angiography is the potential to obstruct sites of bleeding endovascularly using angioembolization

45. Thank you