Penetrating injuries by Professor Mark Midwinter

Professor Mark Midwinter: Penetrating injuries.
From CICM ASM PROGRAM 2019.

1. Penetrating Injuries Mark Midwinter MD FRCS Professor Clinical Anatomy School of Biomedical Sciences

2. Penetrating Injuries Where has it gone? Injuring what structures With what energy?

3. Ballistics As with any trauma, its all to do with energy transfer from weapon to the tissues. Depends on : Available energy (KE=1/2mv 2 ) Weapon type Range Trajectory The tissue structure & properties Vital structures KE in Joules Rifle bullets 1000 - 15,000 Hand guns bullets 300 - 500 Fragments 5 - 150 Air rifle pellet 10

4. Contamination

5. Friable : Brain, capsule enclosed solid organs (e.g. liver) Elastic: Skeletal muscle Indirect: Fracture without direct contact, Spinal cord damage, arterial intimal damage

6. Penetrating Torso Trauma Selective non-operative management of blunt trauma is accepted. Penetrating torso trauma had been considered to mandate surgical exploration. What is the evidence? What and when can the approach be tailored? When to Operate? What to do?

7. Morbidity of non-therapeutic intervention Morbidity / mortality of failure to intervene

8. http:// www.westerntrauma.org /algorithms/ algorithms.html

9. EMERGENCY ROOM THORACOTOMY Velmahos et al. in a retrospective study of 670 cases with penetrating trauma reported an overall survival of 8.3 % for stab wounds and 4.4 % for GSW

10. EMERGENCY ROOM THORACOTOMY

11. INDICATIONS FOR EMERGENT OPERATING ROOM THORACOTOMY Patients with severe hypotension require an emergency thoracotomy without any delays.

12. Abdominal Stab Injuries Changes in methods of evaluation have reduced the number of negative laparotomies from 14–45 %, to 7–10%. Negative laparotomy is associated with a 5 % to 22 % complication rate. The main objection to selective conservatism or serial physical examination is the potential of delay in repair of the injuries. [ Taviloglu K, et al. Abdominal stab wounds: the role of selective management. Eur J Surg 1998;164(1):17–21 Boström L, Heinius G, Nilsson B: Trends in the incidence and severity of stab wounds in Sweden 1987–1994. Eur J Surg 2000;166(10):765–70]

13. Laparoscopy The main advantages of laparoscopy are: Diagnosis of peritoneal penetration, bleeding, solid organ injury. diaphragmatic injury, The limitations are: diagnosing hollow viscus retroperitoneal injuries

14. Annals of Surgery • Volume 249, Number 4, April 2009 195 patients with liver gunshot injuries were treated. Of these, 132 (67.7%) had an indication for emergency laparotomy and underwent therapeutic laparotomy.

15. J Trauma. 2009;66:593– 601.

16. https:// www.east.org /education/practice-management-guidelines Practice Management Guidelines for Nonoperative Management of Penetrating Abdominal Trauma Eastern Association for the Surgery of Trauma Class I: Prospective, randomized clinical trials Class II: Clinical studies in which data was collected prospectively or retrospective analyses based on clearly reliable data Class III: Studies based on retrospectively collected data Recommendations were classified as Level 1, 2, or 3 according to the following definitions: Level 1: The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data, however, strong Class II evidence may form the basis for a Level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a Level 1 recommendation. Level 2: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence. Level 3: The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

17. Level 1 Recommendations Insufficient data

18. Patients who are haemodynamically unstable or who have diffuse abdominal tenderness after penetrating abdominal trauma should be taken emergently for laparotomy. Patients with an unreliable clinical examination (i.e., severe head injury, spinal cord injury, severe intoxication, or need for sedation or intubation) should be explored or further investigation done to determine if there is intraperitoneal injury. Level 2 Recommendations

19. Others may be selected for initial observation. In these patients: 1. Triple-contrast (oral, intravenous, and rectal contrast) abdominopelvic computed tomography (CT) should be strongly considered as a diagnostic tool to facilitate initial management decisions as this test can accurately predict the need for laparotomy. 2. Serial examinations should be performed, as physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen. Patients requiring delayed laparotomy will develop abdominal signs. 3. If signs of peritonitis develop, laparotomy should be performed. 4. If there is an unexplained drop in blood pressure or haematocrit, further investigation is warranted. Level 2 Recommendations

20. i. The vast majority of patients with penetrating abdominal trauma managed non-operatively may be discharged after twenty-four hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. ii. Patients with penetrating injury to the right upper quadrant of the abdomen with injury to the right lung, right diaphragm, and liver may be safely observed in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness. iii. Angiography and investigation for and treatment of diaphragm injury may be necessary as adjuncts to initial nonoperative management of penetrating abdominal trauma. iv. Mandatory exploration for all penetrating renal trauma is not necessary. Level 3 Recommendations

21. PRACTICE MANAGEMENT GUIDELINES FOR PROPHYLACTIC ANTIBIOTIC USE IN PENETRATING ABDOMINAL TRAUMA Level I: There is sufficient Class I and II data to recommend a single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage as a standard of care for trauma patients sustaining penetrating abdominal wounds. Absence of a hollow viscus injury requires no further administration.

22. PRACTICE MANAGEMENT GUIDELINES FOR PROPHYLACTIC ANTIBIOTIC USE IN PENETRATING ABDOMINAL TRAUMA Level II: There is sufficient Class I and Class II data to recommend continuation of prophylactic antibiotics for only 24 hours in the presence of injury to any hollow viscus.

23. PRACTICE MANAGEMENT GUIDELINES FOR PROPHYLACTIC ANTIBIOTIC USE IN PENETRATING ABDOMINAL TRAUMA Level III: Vasoconstriction alters the normal distribution of antibiotics, resulting in reduced tissue penetration. There is insufficient clinical data to provide meaningful guidelines for reducing infectious risks in trauma patients with hemorrhagic shock.

24. Endovascular

25. Summary Haemodynamic stability is key to decision making. Serial examination and monitoring Non-operative management can be practiced but requires a system to closely monitor and regularly reassess the patient’s status. Treat the wound not the weapon

26. Questions?