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Abd Trauma - Cindy Kin

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					Abdominal Trauma


        Cindy Kin

   Trauma Conference
     8 January 2007

 Stanford General Surgery
           Blunt 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 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 resuscitation
CXR, Pelvic X-ray
FAST v DPL v CT
Labs: Hct, WBC, amylase, UA, ABG, T+C
            Blunt Abdominal Trauma

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
              Blunt Abdominal Trauma

              CT        FAST                   DPL
Accuracy      96%       95-99%                 95%
Sensitivity   97%       90-92%                 100%
Specificity   95%       88-90%                 85%
Drawbacks Stable pts Cannot evaluate retroperitoneum.
          only       Cannot identify source of fluid.
                        0.5% miss intestinal
                        perforation; cannot
                        distinguish blood v
                        bowel contents
               Blunt Abdominal Trauma
            INDICATIONS FOR LAPAROTOMY
Shock with
expanding abdomen,
pnemoperitoneum,
retroperitoneal air
                                            Peritoneal signs,
                                             HD unstable,
                                             sepsis
Stable w/
  peritoneal signs        +
                                    equivocal   Observe,
                      Imaging:
                                                +/- re-image
                      CXR
                      FAST/DPL/CT
           Blunt Abdominal Trauma

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
               Blunt Abdominal Trauma

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
            Blunt Abdominal Trauma
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
                Blunt Abdominal Trauma

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%
                Blunt Abdominal Trauma

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
                   Blunt Abdominal Trauma
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.
                  Blunt Abdominal Trauma

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
                 Blunt Abdominal Trauma

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.
                 Blunt Abdominal Trauma

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 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.
           Penetrating Abdominal Trauma

Evaluation of Stab Wounds
• Local exploration                      • FAST
• DPL                                       – Limited, high false
  –   5cc gross blood on aspiration
  –   >20K RBC/mm3
                                              negative rate
  –   >500 WBC/mm3                          – Useful for pericardial
  –   >175U amylase/100mL                     injuries
  –   Bacteria                           • Diagnostic laparoscopy
  –   Bile, Food particles
                                            – Useful for assessing
• CT                                          peritoneal penetration,
  – Limited ability to dx hollow organ        diaphragm injury
    injury
                                            – Shorter LOS than
  – Useful for posterior SW
                                              negative laparotomy
          Penetrating Abdominal Trauma

            Stab Wounds: Stratification by loci

   Lower Chest
                                             Flank



Anterior Abdominal                            Back

                     Peristernal Potential
                           Mediastinal
               Penetrating Abdominal Trauma

                  Stab Wounds: Stratification by loci

     Lower Chest
                                                   Flank



Anterior Abdominal                                  Back
  Explore locally, manage
  expectantly with serial PE
                           Peristernal Potential
                                 Mediastinal
               Penetrating Abdominal Trauma

                  Stab Wounds: Stratification by loci

     Lower Chest
                                                     Flank
                                                   explore locally
                                                   triple contrast CT

Anterior Abdominal                                     Back
  Explore locally, manage
  expectantly with serial PE
                           Peristernal Potential
                                 Mediastinal
               Penetrating Abdominal Trauma

                  Stab Wounds: Stratification by loci

     Lower Chest
                                                     Flank
                                                   explore locally
                                                   triple contrast CT

Anterior Abdominal                                     Back
  Explore locally, manage
  expectantly with serial PE                        admit for obs

                           Peristernal Potential
                                 Mediastinal
               Penetrating Abdominal Trauma

                  Stab Wounds: Stratification by loci

     Lower Chest
    ?Thoracoscopy,
                                                     Flank
     Laparoscopy                                   explore locally
                                                   triple contrast CT

Anterior Abdominal                                     Back
  Explore locally, manage
  expectantly with serial PE                        admit for obs

                           Peristernal Potential
                                 Mediastinal
               Penetrating Abdominal Trauma

                  Stab Wounds: Stratification by loci

     Lower Chest
    ?Thoracoscopy,
                                                      Flank
     Laparoscopy                                    explore locally
                                                    triple contrast CT

Anterior Abdominal                                      Back
  Explore locally, manage
  expectantly with serial PE                         admit for obs

                           Peristernal Potential
                                 Mediastinal
                          CVP monitor, U/S
                          Observe >6h, repeat CXR
                Penetrating Abdominal Trauma
                              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
          Penetrating Abdominal Trauma
  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
           Penetrating Abdominal Trauma
              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
           Penetrating Abdominal Trauma
              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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