Abd Trauma - Cindy Kin (2)

Abdominal TraumaAbdominal Trauma

Cindy Kin

Trauma Conference8 January 2007

Stanford General Surgery

Blunt Abdominal TraumaBlunt Abdominal Trauma

Mechanisms• Direct impact• Acceleration-deceleration forces• Shearing forces

• No correlation between size of contact area and resultant injuries.

• Abdomen = potential site of major blood loss.

Initial Evaluation and TreatmentInitial Evaluation and Treatment

Is there a surgical intraabdominal injury?

PE: guarding, peritoneal signs, tenderness, nausea. DRE.Lower rib fxs: 10-20% a/w spleen/liver injury Seatbelt sign a/w intestinal injury and mesenteric tears. Direct blunt trauma: rupture/tear of solid organs.Flank pain or contusion often late signs of retroperitoneal bleed

Rapid resuscitationCXR, Pelvic X-rayFAST v DPL v CTLabs: Hct, WBC, amylase, UA, ABG, T+C


INDICATIONS for CT• Blunt trauma with closed head injury• Blunt trauma with spinal cord injury• Gross hematuria• Pelvic fx, +/- suspected bleeding• Pt requiring serial exams, but will be lost to PE for prolonged

period (ie orthopedic procedures, general anesthesia)• Pts with dulled or altered sensorium

CONTRAINDICATIONS: unstable patients


CT FAST DPL

Accuracy 96% 95-99% 95%

Sensitivity 97% 90-92% 100%

Specificity 95% 88-90% 85%

Drawbacks Stable pts only

Cannot evaluate retroperitoneum. Cannot identify source of fluid.

0.5% miss intestinal perforation; cannot distinguish blood v bowel contents


Shock with expanding abdomen,pnemoperitoneum,retroperitoneal air

INDICATIONS FOR LAPAROTOMY

Imaging:CXRFAST/DPL/CT

Stable w/ peritoneal signs

Peritoneal signs, HD unstable, sepsis

+

equivocal Observe,+/- re-image


ROLE OF DIAGNOSTIC LAPAROSCOPY• Hemodynamically stable patients• Inadequate/equivocal FAST or borderline DPL

(80K-120K RBC/HPF)• Intermittent mild hypotension or persistent

tachycardia• Persistent abdominal signs/symptoms• Potential to decrease # of nontherapeutic

laparotomies


PREDICTIVE VALUE OF QUANTIFYING BLOOD VOLUME ON FAST EXAM

• Hemoperitoneum score on ultrasound a better predictor of need for therapeutic laparotomy than admission blood pressure and/or base deficit.

• Hemoperitoneum characterized by measurement and distribution, scored

• Ultrasound score >=3 statistically more accurate than combination of SBP and base deficit in determining which patient will undergo a therapeutic abdominal operation

• 83% sensitivity, 87% specificity, 85% accuracy– McKenney et al, J Trauma 50:650-656, 2001


HEPATIC AND SPLENIC INJURIES• Unstable patients: mandatory laparotomy• Stable patients: selective nonoperative approach

Hepatic injury -Usually venous bleeding-Grade I-III: 94% success w/ nonop treatment-Grade IV-V: 20% amenable to nonop tx-HD stability, stable Hct, observation-Complications: delayed hemorrhage, bile

leak, biloma, intra/peri hepatic abscess. -If stable with ongoing bleeding - angiographic

embolization


SPLENIC INJURIES• Often arterial hemorrhage, therefore nonoperative

management less successful.

• Predictive factors for nonop success: – Localized trauma to flank/abdomen– Age<60– No associated trauma precluding obs– Transfusion <4u prbcs– Grade I-III

• Grade IV-V: almost invariably require operative intervention• Delayed hemorrhage (hours to weeks post-injury): 8-21%


RETROPERITONEAL HEMORRHAGE • Source: aorta, IVC, kidneys and ureters, pancreas, pelvic fx,

retroperitoneal bowel. • Minimal signs on examination; flank pain and contusion are late findings• FAST/DPL negative; CT can identify


DUODENAL AND PANCREATIC INJURY • Subtle diagnosis: amylase abnl, obliteration of R psoas or retroperitoneal

air on plain abdominal films. • DPL unreliable. • At laparotomy, central upper abdominal retroperitoneal hematoma, bile

staining, or air: mandates visualization and examination of panc/duo

• Duodenal injury: – 80% lacs (G I-III) - primary repair– 10-15% RYDJ, pyloric exclusion, Whipple

• Pancreatic injury– Late complications: time from injury to tx

• Abscess, pseudocyst, fistula.


DIAPHRAGMATIC RUPTURE• 3-5% of all abdominal injuries, L>R • May p/w few signs, need high index of suspicion

– Injury mechanism: compartment intrusion, deformity of steering wheel, need for extrication, fall from great height

– Prominence/immobility of L hemithorax– NGT in chest, bowel sounds in thorax– CXR: (50% with non-dx initial CXR):

• Obliteration of L diaphragm on CXR• Elevation/irregularity of costophrenic angle• Pleural effusion

• Confirm with GI contrast studies, dx laparoscopy • Ex-lap and repair


SMALL BOWEL INJURY

• Mechanism: rapid deceleration with compression, shearing• Often at points of fixation: Treitz, ileocecal valve, prior adhesions,

mesentery.• Chance fracture (transverse fx of lower thoracic/lumbar vertebral body)

raises index of suspicion for SB injury• Dx: DPL may be (-) for 6-8h after intestinal perforation, Clinical signs

absent until 6-12h post-injury. • Delayed perforation: due to direct injury, transmural contusion, ischemia

from mesenteric vascular injury; usually presents w/in days.


INJURY TO COLON AND RECTUM

• Mechanism: rapid deceleration with steering wheel compression• uncommon• Disruptions of colonic wall or avulsion injury of mesentery• Present with hemoperitoneum, peritonitis.

Penetrating Abdominal TraumaPenetrating Abdominal Trauma

Evaluation• Any penetrating wound

between nipples and gluteal crease = potential intra-abdominal injury.

• Stab wounds: stratify based on location

• GSW: higher potential for serious injury.


Evaluation of Stab Wounds• Local exploration• DPL

– 5cc gross blood on aspiration– >20K RBC/mm3– >500 WBC/mm3– >175U amylase/100mL– Bacteria– Bile, Food particles

• CT– Limited ability to dx hollow organ

injury– Useful for posterior SW

• FAST

– Limited, high false negative rate

– Useful for pericardial injuries

• Diagnostic laparoscopy

– Useful for assessing peritoneal penetration, diaphragm injury

– Shorter LOS than negative laparotomy


Stab Wounds: Stratification by loci

Lower Chest

Anterior Abdominal

Flank

Peristernal Potential Mediastinal

Back



Lower Chest

Anterior Abdominal Explore locally, manage expectantly with serial PE

Flank


Back



Lower Chest


Flankexplore locally

triple contrast CT


Back



Lower Chest



triple contrast CT


Backadmit for obs



Lower Chest?Thoracoscopy,

Laparoscopy



triple contrast CT


Backadmit for obs



Lower Chest?Thoracoscopy,

Laparoscopy



triple contrast CT

Peristernal Potential MediastinalCVP monitor, U/S

Observe >6h, repeat CXR

Backadmit for obs


Gunshot Wounds• Usually require urgent exploration• Evaluation for peritoneal penetration v tangential GSW.

– CT, diagnostic laparoscopy– Use of DPL controversial due to high false negative rate

• Ballistics: – Civilian=lower velocity handgun missiles; military = higher velocity rifle missiles– Permanent and temporary cavities: Yaw, Bullet size and type– Shotgun:

• Short range: high-velocity and more concentrated• Distant range: multiple low-velocity projectiles, more diffuse, less severe

• Antibiotics: cefotetan or cefoxitin in ED


ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATING GSW AND NEED FOR LAPAROTOMY

• 66 GSW underwent DL, 2/3 of GSW in upper torso• Peritoneal penetration ruled out in 62%• 29% had therapeutic ex-lap, 5% had non-therapeutic ex-lap,

4% had negative ex-lap• Hospital stay:

– 4.3 days - negative DL and associated injuries– 8.6 days - laparotomy– 1.1 days - negative DL and no associated injuries.

– Fabian et al, Ann Surg 1993; 217:557


IMPACT OF DIAGNOSTIC LAPAROSCOPY ON NEGATIVE LAPAROTOMY RATE

• Retrospective review 817 pts who underwent ex-lap for abdominal GSW over 4yr: negative ex-lap rate = 12.4%– 22% morbidity, LOS 5.1days

• Review of 85 pts with abdominal GSW evaluated with DL– Negative DL in 65%, no missed injuries, no subsequent need for ex-lap;

3% morbidity rate (one pt had urinary retention), LOS 1.4days– Positive DL in 35%, 28 of 30 underwent ex-lap, 86% therapeutic and

14% nontherapeutic (remaining 2 were observed for nonbleeding liver lacs)

– Sosa et al. J Trauma 1995;38(2):194


IMPACT OF DIAGNOSTIC LAPAROSCOPY ON NEGATIVE LAPAROTOMY RATE

• Prospective study of 121 patients with tangential GSW, HD stable• 65% negative DL• Of 25% positive DL, 92.8% (39) underwent ex-lap

– 82% (32) therapeutic, 15.4% (6) nontherapeutic, 2.5% (1) negative

• No false negative DLs, no delayed laparotomies• Sensitivity for peritoneal penetration 100%

– Sosa et al. J Trauma 1995;39(3):501

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Abd Trauma - Cindy Kin (2)