Management of blunt abdominal trauma Subash Gupta Gyan Burman Liver Surgery Unit Sir Ganga Ram Hospital New Delhi Plan • ABC of resuscitation • ATLS • DPL/US /CT scan • Damage control surgery • Specific issues in surgical care Resuscitation • Circulation – Two large bore(16G) – 2 L Ringer’s lactate • Rapid responder: surgical evaluation necessary initially • Transient response: ongoing loss/inadequate resuscitation, rapid surgical intervention • Minimal or no response, immediate intervention – Pump failure, myocardial contusion/tamponade • Permissive hypotension, – ‘Pop the clot’ – not with head injury Permissive Hypotension for Trauma Resuscitation Jon Hoerner, trauma.org (7:10) October 2002 Please mark my word. Within no less than 10 years, probably even less than 5 years, any [one] that raises the blood pressure to higher than 3/4 the pre injury level, especially if using crystalloid solutions will be severely criticized as violating one of the indicators, whether the injury be penetrating, blunt, elderly, child, or one's own self or family. Also mark this down on this date. The final target for a prehospital or EC measured BP will be that greater than 80 SYSTOLIC will be the level that the QA moral police will cite that those of you who believe in two large bore IVs, Rapid infusors, interosseous and sternal infursors, the 3 to 1 rule, and cyclic hyper resuscitation as causing unnecessary complications, deaths, and costs. Ken Mattox. Trauma.Org Trauma-List, 30th August 2002 Abdominal trauma • Peritoneal cavity: major occult loss • Assessment: accurate diagnosis not important, but recognise that abdominal injury exists • Special diagnostic tests – Equivocal, unreliable, impractical – Diagnostic lavage/CT scan • FAST Liver Trauma • Conservative: paradigm shift – Before 1993, routine operative treatment – Between 1993 - 1994, selective non operative management – Between 1994 - 1998, non operative management standard practice Conservative treatment • Avoids laparotomy and complications of laparotomy • Decreases blood transfusion • High success rate: irrespective of CT extent of injury, extent of haemoperitoneum • No evidence to suggest missing of other injuries • Contrast blush or ongoing haemorrhage indication for embolization Liver trauma (contd.) • Blunt • Gunshot/penetrating: explore • Angiogram, bile duct complications • Perihepatic packing Operative technique • Suturing – Liver suture • Resection • ?Mesh compression • Inflow occlusion Operative technique • Exposure and haemostasis – Mobilisation – Direct pressure, electrocautery, argon beam coagulation, finger fracture with direct ligation of bleeders • Pringle manoeuvre, • Avoid deep liver sutures • Vascularised omental flap for tamponade Transarterial embolisation Pancreas • Explore and drain • Distal pan/splenectomy • Recognise duodenal injury • Refer or call for help if needed pancreaticoduodenectomy – Whipple’s resection (SGRH, < 5% mortality) Spleen • Conservation – Key is to be able mobilise spleen outside the incision • Delayed rupture ??? • Splenic conservation data?? Damage Control surgery Damage control • Control haemorrhage and contamination • Resuscitation: correct hypothermia, acidosis and coagulopathy • Return to OT: definitive repair • Post operative care Damage Control Surgery • Phase I – Rapid termination of operative procedure – Arrest of bleeding – Removal of contamination • Phase II – Correction of physiologic abnormalities – Acidosis, hypothermia, coagulopathy • Phase III – Definitive surgery What is different? • Surgical dogma: complete the operation – 1908: Pringle packing of liver injury – Fell out of favour, not used in Vietnam war – 1981: Feliciano 90% survival by packing in severe liver injury – 1983: Stone abbreviated laparotomy, 11/17 survivors • Rotundo: damage control surgery, 1990s The lethal triad Bleeding coagulopathy Acidosis hypothermia Hypothermia • Fluids needed for resuscitation • Exposure of body • Large incision and long duration of procedure • Blood loss, decreased O2 consumption and decreased heat production Effects of hypothermia • 100% mortality if core temp < 32C • Diminished cardiac function • Coagulopathy: clotting cascade is a temp. dependent reaction, fibrinolysis, platelet dysfunction/sequestration Acidosis • Lactate production from anaerobic metabolism • Failure to normalize lactate concentration by 48 hours, mortality between 86 to 100% • Systemic effects: decreased contractility, impaired response to catecholamines and ventricular arrhythmias • Coagulopathy worsened Coagulopathy • Dilution worsens coagulopathy • Dilution and hypothermia additive • Acidosis worsens coagulopathy Damage control procedure • ABC • Life threatening bleeding: rush to OR • Temp elevated, Warm ventilator circuit, Bair hugger, early replacement of coagulation factors • No effective guidelines when to initiate damage control Abdomen • Liver packing • Ligation of blood vessels • Placement of intraluminal shunts • Chest tubes in to aorta or IVC • Inflatable balloon catheters Abdomen II • Resect hollow viscus with stapler • Biliopancreatic injuries by closed suction drainage • Ligation of ureter or tube ureterostomy • Formal closure – Abdominal compartment syndrome – ARDS – MOF • Closure of skin, mesh Stage II, resuscitation • Similar principles as in OR • ? Continuous arteriovenous rewarming • Reduces time to normothermia • Resuscitation requirements • Early mortality • Correction of acidosis: Hyperchloremic acidosis versus lactic acidosis, anion gap narrow versus widened • Correction of coagulopathy Definitive operation • Attempt to return to OR within 72 hours • Remove packs • Complete exploration • Haemostasis • Small bowel continuity • Large bowel exteriorization Abdominal compartment syndrome • End organ dysfunction secondary to intraabdominal hypertension – Tense abdomen, – Elevated peak airway pressure – Inadequate ventilation – Inadequate oxygenation – Oliguria • Reversed with decompression • Bladder pressure >16mmHg – Full blown syndrome >35 mmHg • Worse with fascial closure Control of bleeding • Bleeding DU, assistant to compress aorta against spine while taking stitches • Leaking aneurysm: mobilise left lobe, loop oesophagus divide crus of diaphragm and control supracoeliac aorta • Ligation of internal iliac vessels if there is retroperitoneal bleeding, pelvic trauma Summary • Important to recognise when to stop operating: stop the bleeding and deal with contamination • Discretion is better part of valour • Surgery should not be delayed till patient is adequately resuscitated, this can happen concurrently in OR.
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