Blunt Abdominal Trauma

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Blunt Abdominal Trauma

• NI Regional Programme
• for
• Specialist General Surgical Registrars

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Anatomy

• 4 regions
• Intra-thoracic
• Intra-abdominal cavity
• Pelvis
• Retro-peritoneum

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Frequency of Organ Injury

• Spleen 46
• Liver 33
• Mesentery 10
• Urological 9
• Pancreas 9
• Small bowel 8
• Colon 7
• Duodenum 5

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Clues from the history
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Clues from the history

• Rapid deceleration
• Use of lap belt
• History of ejection
• Fall from great height
• 10 of admissions to trauma centres

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Examination

• Inspection
• Palpation
• Auscultation
• PR
• NG aspirate

• contusions/abrasions
• seat belt sign
• tenderness
• (50 associated injury rate)
• guarding
• diminished bowel sounds
• blood - sphincter tone -defect
• blood

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Associated with Fractures

• left lower six ribs
• right lower six ribs
• upper lumbar vertebra
• transverse process
• pelvis

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Associated with Fractures

• left lower six ribs 20 spleen
• right lower six ribs 10 liver
• upper lumbar vertebra pancreas duodenum
• transverse process kidney
• pelvis bladder urethra rectum vascu
  lar

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Reliability of Clinical Evaluation

• Low sensitivity
• Unreliable in 34 - 45 patients
• Why?

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Reliability of Clinical Evaluation

• Low sensitivity
• Unreliable in 34 - 45 patients
• Why? head injury
• spinal injury
• alcohol
• drug use

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Investigative Techniques

• Laparotomy
• Diagnostic Peritoneal Lavage
• Computer Tomography
• Ultrasound Scanning
• Laparoscopy

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Immediate Laparotomy
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Immediate Laparotomy

• Abdominal distension hypotension
• Peritonitis
• Abdominal visceral injury
• rectal bleeding and pelvic fracture
• ruptured diaphragm
• peritoneal air on CXR

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Indications for Investigation

• When abdominal examination is
• Unreliable (altered mental state)
• Equivocal
• Unexplained hypotension or shock

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DPL - Contraindications
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DPL - Contraindications

• Absolute
• Patient needs laparotomy
• Relative
• Multiple previous operations
• Pregnancy (Third trimester)

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DPL - Methods

• Open
• Semi-closed
• Closed

• In common
• Co-operative patient
• Sterile precautions
• Warm isotonic fluid (1L)
• Empty bladder
• NG tube preferred
• Roll syphon

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DPL - Choice of Method

• Open
• Abdominal distension
• Previous surgery
• pregnancy
• portal hypertension
• coagulopathy

• Closed
• gross obesity
• High
• Pelvic
• pregnancy
• prev incision

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DPL - Positive Results
?
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DPL - Positive Results

• Gross blood gt10 ml
• Red cells gt100,000 /mm3
• White cells gt500 /mm3 (?)
• Amylase gt 175u/dl
• gross GI contents
• bacteria on gram stain

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DPL - Equivocal Results

• Red cells 50,000 - 100, 000 /mm3
• White cells 100 - 500 /mm3
• Found in 2 - 6 DPL
• Serious intra-abdominal injury in 86
• Repeat lavage ?

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DPL - advantages

• Simple
• Fast
• Economical
• Reliable
• accuracy 97.3 - 99.1
• false positive 0.2 - 1.4
• false negative 1.2 - 1.3

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DPL - disadvantages

• Oversensitive
• Lacks specificity
• Fails to investigate
• Complication rate

• 6-25 non-therapeutic
• laparotomy rate
• Source
• Amount
• Continuation
• Retroperitoneum
• 1 - 1.7

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CT - contraindications

• Absolute
• Patient needs laparotomy
• Unstable patient

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CT - advantages

• Non-invasive
• Reliable Accuracy 91 - 98.3 Sensitivity 60
  - 85 Specificity 100
• Delineate specific organ injury
• Haemoperitoneum gt 100ml
• Assesses the retroperitoneum

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CT - disadvantages

• Need for transfer to scanner
• Need cooperative patient
• Complications related to contrast
• Ionizing radiation
• Cost Time Personnel
• Usefulness in hollow viscus injury ?

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FAST Focused abdominal sonography for trauma

• To identify if the abdomen is the source of
  haemorrhage in unstable trauma patients ? - FLUID
• To evaluate those with no major risk factors for
  abdominal trauma

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FAST - Results

• Reliability
• accuracy 86 - 97
• sensitivity 88 - 91.7
• specificity 94.7 - 99
• Can detect 70 ml fluid

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USS- Advantages

• Safe (Non-invasive)
• Cheap
• Rapid
• Can be performed in resuscitation area
• Can be used to follow-up injuries being
• managed conservatively

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USS - Disadvantages
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USS - Disadvantages

• Training required
• Interobserver variation
• Difficulties subcutaneous emphysema gas
  distension morbid obesity
• Cannot determine type of fluid
• Inadequate detection of visceral perforation
• Accuracy improves on repeated scanning

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USS - Training

• What is adequate ?
• Few hours training
• 2 months - 3 years experience
• 500 studies
• Interpretation and performance sensitivity
• stable after 100 examinations

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Laparoscopy - requirements

• Stable patient
• Patient secured to table (steep positions)
• GA
• No extensive intra-abdominal adhesions
• Suction irrigator catheter
• Angled laparoscopes
• Experienced laparoscopic surgeon

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Laparoscopy - Advantages

• Can be used as adjunct to CT and
• allows direct visualisation of injury
• allows assessment of whether there is ongoing
  bleeding

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Laparoscopy - Disadvantages
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Laparoscopy - Disadvantages

• Unsuitable for unstable patients
• Performed in operating room
• Difficulty to examine entire bowel length
• Difficulty to examine retroperitoneum
• Tedious
• Significant learning curve
• Requires presence of surgeon with expertise

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Choice of investigation

• DPL
• CT Scan
• USS (FAST)

• Unstable patient
• to assess for blood and
• need for laparotomy
• Stable patient
• to define site of injury
• may permit non-operative Tx
• Unstable patient
• Requires experience

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Laparotomy for Trauma

• Aims
• Stop bleeding
• Limit Contamination
• Method
• Midline
• Too large

• Priorities
• Bleeding control
• Haemodynamic stability
• Contamination control
• Full inspection

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Bleeding Control
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Bleeding Control

• Source Liver, spleen, mesentery
• 4 quadrant packs
• Pack solid organs
• Forceps or soft bowel clamp to bleeding mesentery
• Proximal clamping
• Abdominal aorta manual compression

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Haemodynamic Stability

• No further surgery until stability achieved
• Then remove packs in order
• Start with safest pack
• Control bleeding with
• clamps
• sutures
• repack

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Contamination Control

• Control with bowel clamps
• sutures
• staples

Full Inspection
Ant/Post stomach SB LB D4 H B T
Pancreas Diaphragm Central Retroperitoneum
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Damage Control LaparotomyBackground

• 82 deaths following liver trauma due to
• Uncontrollable haemorrhage
• Progressive coagulopathy
• Hypothermia
• Acidosis
• Elerdin et al 1979

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Damage Control Laparotomy

• Procedure
• Intra-abdominal pack tamponade
• Abortion of laparotomy
• Temporary abdominal Closure
• Correction of
• coagulopathy, hypothermia, acidosis
• Later completion of procedure (Staging)

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Damage Control Laparotomy
When ?
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Damage Control Laparotomy

• When ?
• Inability to achieve haemostasis
• Inaccessible major venous injury
• Need for prolonged procedure
• Control of other injuries
• Inability to close abdomen
• Relook necessary

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Abdominal Closure

• Why ?
• Limit heat and fluid loss
• Protect viscera
• How ?
• Towel Clips Vicryl mesh
• Opsite sandwich Bogota Bag

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Damage Control Surgery When to Re-open

• Normal physiology restored
• restoration of body temperature
• correction of clotting
• optimization of oxygen delivery
• Within 24-48 hours of surgery
• Earlier if persistent bleeding
• Compartment Syndrome

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Abdominal Wall Reconstruction

• After definitive surgery
• No further operations planned
• Primary closure
• Close sheath only
• Bogota bag (subsequent bad suture)
• Synthetic sheets
• Vicryl mesh Gore-Tex sheets

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Damage Control LaparotomyOutcome

• Who?
• ISS gt 35
• Coagulopathy (PTTgt19 secs)
• Shock gt 70 minutes
• pH lt7.2
• Survival 48
• Garrison et al 1996

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Hepatic Injuries I

• Most catastrophic bleeding is venous
• Temporary control of bleeding with packs
• Divide triangular ligaments
• Insert Packs above and below liver
• ? Vicryl mesh
• ? Pringle manoeuvre (divide gastrohepatic
  ligament)(vascular clamp)(lt30 minutes)

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Hepatic Injuries II

• Keep surgery to minimum
• Omentum to cover raw surfaces
• Remove packs within 24-48 hours
• Refer to hepatobiliary unit ?
• Angiography

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Liver - Non-Operative Approach

• Who ?
• Blunt trauma
• Stable
• Identified on CT Scan
• Exclusion of other injuries
• Observe in Specialist Centre

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Liver - Non-Operative Approach
?

• Risks
• When to stop ? (2-11)

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Liver - Non-Operative Approach

• Risks
• Missed injuries to other viscera
• Delayed rupture of liver (rare)
• Biliary leaks (ERCP or Percutaneous)
• When to stop ? (2-11)
• Haemodynamic instability
• Non-hepatic injuries (prev unidentified)
• Transfusion requirement gt2 units/day

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Splenic Injuries

• Mobilise from bed
• Protect tail of pancreas
• Protect greater curvature of stomach
• ? Vascular clamp to splenic pedicle
• ? Conserve (vicryl mesh bag)
• Splenectomy (OPSI Penicillin/HIB/P-vac)

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Spleen - Non-Operative Approach

• Who ?
• Long term advice ?

?
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Spleen - Non-Operative Approach

• Who ?
• Stable
• Identified on Scan (USS/CT Scan)
• Exclusion of other injuries
• Observe in HDU (CV monitoring)
• Bed rest for 48 hours
• Restrict activity for 6 weeks
• Avoid contact sports for 6months

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Spleen - Non-Operative Approach

• Risks
• Missed injuries to other viscera
• Delayed rupture of spleen
• When to stop ? (0-30)
• Haemodynamic instability
• Signs of peritonism
• Transfusion requirement gt2 units/day

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Colon Injuries

• Primary repair or Colostomy?

?
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Colon Injuries

• Primary repair or Colostomy?
• Shock
• major blood loss
• more than 2 organs injured
• more than minimal faecal contamination
• delay gt 8 hours
• PATI score gt25

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Colon Injuries

• Physiologically challenged
• splanchnic hypoperfusion
• local tissue hypoxia
• Anastomotic failure
• Stoma
• Damage Control (staple close abdomen restore
  haemodynamics relook surgery)

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Blunt Pancreatic Injuries

• CT 85 accurate
• Drain
• ? Pyloric exclusion

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Dilemmas IIntra-abdominal and Pelvic Haemorrhage

• Unstable
• DPL positive -gt laparotomy then Ext Fix
• DPL weakly positive -gtExternal Fixator
• DPL negative -gtExternal Fixator
• if then stable -gt CT scan
• may need angiogram embolization

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Trauma - Scoring Systems

• PATI (Penetrating Abdominal Trauma Index)
• Score value of 1-5 for each organ injured
• Risk factor for each organ (1-5)
• Organ score score x risk factor
• PATI score organ score organ score
• American Association for Surgery of Trauma -
  Organ Scale for each organ

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Pancreatic Injuries

• Penetrating
• Explore - Kocherization
• divide ligament of Treitz
• open lesser sac
• splenic hilum
• Blunt
• CT 85 accurate
• Drain ? Pyloric exclusion