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Abdominal traumaAbdominal trauma
Complex lesions
In only 40% of cases trauma is isolated in the abdominal wall
Combination of organ affected is extreme– Intraperitoneal (solid or hollow organs)– Retroperitoneal
Mechanism of trauma
Direct effect – weapon directly affects the abdominal viscera
Kinetic effect: acceleration or deceleration of the abdominal viscera: weight of the intra-abdominal viscera is multiplied by acceleration
Counter hit on the bony structures in proximity.
Complex lesions
One organ – an exception Complexity means:
– Organs in the same or different anatomical regions
– Multiple trauma / Multiple contusion
Emergency evaluation
ANY traumatized patient should be ragrded as serious until proven different
ATTENTION associated unapparent lesion my be more important then those obvious to clinical investigation
Lesions have to be graded according to their potential risk .
Information from friends, relatives or witnesses – with much care and suspicion
FORENSIC MEDICINE legal aspect are crucial Alcohol consumption
RESUSCITATION
ABC Priority
– Respiratory resuscitaion
– Cardiovascular stability
History taking Moment of aggression Aggressor (relative position to the victim) Weapon Patient’s position on impact Physiologic status of the digestive tract
(stomach) and urinary tract (bladder) Essentials on intestinal transit and urinary
function before and after trauma
History History of present disease
– What happened from the moment of trauma until presentation (there could be hours or days)
– Past medical problems: all very important– Certain pathologies may have additional
significance• Enlarged spleen (diverse cause) may be accessible
to direct trauma and may be more friable• Hernia of any kind• Previous surgical incisions• etc
History taking Previous diseases
– May appear as unessential but can change the course of diseases and produce significant changes in therapy
• Respiratory problems
• Cardiovascular problems
• Allergies
• Liver dysfunction
• Renal failure
• Diabetes
Clinical evaluation Inspection
– Deformities of the general shape of the abdomen
– Aspect of the abdominal muscles: if contracted should suggest peritonitis
– Abdominal movements with respiration and cough
– Anemia– Posttraumatic changes on the skin (impact site
as a mark of trauma, seroma, hematoma, and so on )
Clinical examination Palpation:
– Hypersensiblity of the skin – Pain induced by superficial or deep palpatin– Tumor mass in the structure of the abdominal
wall or in the abdominal cavity – Abdominal guarding
Clinical examination Auscultation
– Absence of intestinal sounds – reflex mechanism (spine injuries) or irritation (abdominal sepsis or hemoperitoneum)
Percution– Free air in peritoneal
cavity– Free liquid in the
peritoneal cavity
Abdominal wall Abdominal wall contusioncontusion
Nonspecific – like all contusions of the soft tissues
Ecchymosis : – Traumatic signature of the
weapon– Immediate after trauma –
superficial injuries– Late – deep structure are
affected– May be at a significant
distance from the impact area – migration of a hematoma by dissection in the soft tissues
Hematoma
Pseudo-tumor mass – accumulation of blood Large lumen vessels Presentation
– Diffuse– Cyst– Pulsating – arterial wound – EMERGENCY
Essential sign – crepitation Possible central fluctuation – liquefaction of the
clot
Special forms of Special forms of abdominal traumaabdominal trauma
Hematoma – rectus abdomini
rupture
Anatomic particularities:– Fascial intersections that
segment the muscle– Rectus sheet– Abundant network of
vessels , large vessels inside the sheet
Hematoma is well circumscribed, in tension, developed between two intersections.
During contraction of the wall: painful and does not disappear inside the abdomen.
Diagnostic: sudden onset, related to trauma are fundamentals in understanding the diagnosis.
Hematoma –psoas muscle
rupture
Anatomic particularities:– Situated deep in
retroperitneum– Adjacent to branches from the
lumber plexus (crural, femurocutaneous, ilio-hypogastric and ilio-inguinal)
Developed in the retroperitoneum and behaves like a deep situated tumoral mass, not well circumscribed, immobile over deep structures.
Disappears during abdominal wall contractions
Diagnostic: sudden onset, related to trauma are fundamentals in understanding the diagnosis
May appear spontaneous
SeromaMorel-Lavallee
Small vessels injury with spontaneous hemostasis – tangential trauma with shearing mechanism
Develops in time, but does not feel the entire space available = fluctuence not always present
Usually normal skin Will be absorbed in time, sometimes requiring
aspiration
Rupture of the diaphragm
Indirect mechanism via an acute increase in abdominal pressure
Direct mechanism – crushing the base of the thorax
False herniation of abdominal viscus in the thorax. (false = no peritoneum)
Respiratory problems due to intrathoracic compression
Digestive problems – difficult to evaluate in a trauma patient with more serious lesions.
Traumatic diaphragmatic hernia
Posttraumatic hernia
Early or late complication of trauma BREAK IN THE MUSCULAR-FASCIAL
LAYER – may be obscured by gravity of initial trauma
In time it develops like a true hernia through a new week point
Symptoms are very similar to all postoperative hernia BUT no scar
Abdominal woundsAbdominal wounds
Classification
Superficial Penetrate
– Perforated
20% of all peace time abdominal trauma
90% of all war time abdominal trauma
Wounds and contusions can be present inthe same time
Non-penetrated abdominal wounds
Diagnostic is essential = lack of penetration
Intact serosal layer – difficult to appreciate especially in a blunt trauma with a wound
DIAGNOSTIC CRITERIA
Anamnesis – Weapon and trajectory – Relative position of aggressor and victim – Direction of the weapon as it hits– Physiologic status– Number of wounds
Local examination
Gentle, after a careful antiseptic preparation of the skin and wound
Use a blunt gentle instrument to probe the wound If not a simple stab wound (that is complex
wounds with non-linear trajectory) the information will always be incomplete. ATTENTION to strata movements between impact and examination
An examination with a negative result is not necessary conclusive
General examination of the abdomen
Look for signs and symptoms suggestive for penetrating and perforated wound
Monitor the clinical status of the patient – that is safe in the case of a negative evaluation (regarding a probable superficial wound) – Admit patient for hospital care for at least 24
hours
Lab exams
Their purpose is to identify signs of major syndromes related to the peritoneal cavity– Peritonitis– Hemorrhage– Intestinal obstruction– Acute pancreatitis
• According to type of wound and trajectory
Surgical evaluation of the abdominal cavity
In this case IT IS a method of EXPLORATION– Laparotomy– Laparoscopy MAJOR LIMITS
• Check the integrity of the peritoneal surface• Check the integrity of viscus• Check for fluid in periteneum TYPE
Andominal exploration should be as complete as possible – HOW MUCH IS COMPLETE
TAKE GOOD CARE
Any abdominal wound (even very small or apparently without significance) can be penetrated. MINIMAL ACCESS SURGERY
A small wound can be accompanied by a big disaster in the abdomen.
Initial evaluation can be misleading
Penetrated wounds
All the abdominal wall has been penetrated (including the parietal peritoneum) but no viscus in injured :– PROTOTYPE: first trocar in laparoscopic
approach It is not common – more frequent with stab
wounds Exploration – same methods
Clinical evaluation
Wound exploration: – How much the instuments can be inserted in
comparison with the width of the abdominal wall = RELATIV
– Is the probe free to move? = RELATIVA
If the wound is large enough abdomina viscus can herniate outside = DIAGNOSTIC
Significance
Major risk for a viscus injury, even if not apparent
Major risk to err due to absence of clinical manifestation at presentation
Risk of infection of the peritoneal cavity In traumatic evisceration – risk of
strangulation
Indications for operation Perforations not conclusive excluded Traumatic evisceration Non-perforant character questionable
(patient unconscious)– Laparotomy– Laparoscopy
Perforated wounds
Symptoms depend on viscus involved and time interval from lesion (25-35% multiple organs affected)
Dg obvious when in the wound– Digestive content OR colonic content OR
blood in quantity larger then we expect ?????– Symptoms develop in time – check for
patients condition
Major clinical presentation
Peritonitis Intraperitoneal
hemorrhage Intestinal
obstruction Upper GI
bleeding Pancreatitis
PERITONITISPERITONITIS
Acute peritonitis
Essentials for diagnostic
Abdominal pain, vomiting, fever, altered general status
Abdominal guarding, localized or generalized abdominal pain. Rebound pain.
LATE – abdominal distension – paralitic ileus
Increased WBC Free fluid in the abdominal cavity
Etiology – extremely diverse
Infections = by far the most frequent – GI tract perforations– GI tract necrosis- ORIGIN: perforation of any cavity with septic content
(urinary, genital, abscesses secondary opened in the free cavity iatrogenic, etc)
Chemical irritation– Perforated ulcer
Primary peritonitis – no cause (diabetes, liver cirrhosis, etc)
Clinical evaluation General signs are dominant
Nausea Vomiting Altered status High fever – septic
fever
WBC Changes in electrolyte
balance
Abdominal signs
Spontaneous abdominal or pain induced by palpation– Localized or generalized– Signs of peritoneal irritation (vibrations transmitted to
parietal peritoneal layer elicit pain)• Pain during coughing• Pain on sudden decompression• Pain on percussion
– Pelvic peritonitis: pain on pelvic or vaginal examination. Rectal examination is essential
Abdominal signsAbdominal guarding
– Muscles adjacent to inflamation becomes spastic
– In generalized peritonitis ABDOMINAL RIGIDITY
– Rigidity disappears in :• Late aspects of peritonitis• Major toxic states• Unusual cases with abdominal wall with no
tonicity
ABDOMINAL SIGNS Paralitic ileus
– Peritoneal inflamation inhibits intestinal motility
– Cardinal signs:• Low amplitude or no
intestinal sounds
• Meteorism
• Passage of flatus or feces stopped
• Vomiting
ABDOMINAL SIGNSAir in the
abdominal cavity– NO pre-hepatic
dullness– Atention:
• Situs inversus
• Chiliaiditi syndrome
ABDOMINAL SIGNS
Imagistic– Plain X-Ray of the abdomen
• Pneumoperitoneum • Air-fluid levels• Thick bowel wall
– CT – may develop the cause in certain cases
Paracentesis – liquid in the abdomen – type of fluid can give a clue + bacteriological examination
Differential diagnosis
Intestinal obstruction Localized infections
(acute cholecystitis) Pancreatitis Renal colic Pneumonia (inferior lobe)
Porphyry Fever of other origin ISTERIA Insect byte Retroperitoneal
hematomas Neurological disorders:
– Spinal injuries– Syphilis of the spinal cord
CONCLUSIONS
Essentials of diagnostic are based on CLINICAL DATA
Signs suggestive for peritoneal irritation JUSTIFY an aggressive surgical exploration