Management of blunt abdominal trauma - PowerPoint by AmnaKhan

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									Management of blunt abdominal

          Subash Gupta
  Gyan Burman Liver Surgery Unit
         Sir Ganga Ram Hospital
               New Delhi
•   ABC of resuscitation
•   ATLS
•   DPL/US /CT scan
•   Damage control surgery
•   Specific issues in surgical care
• Circulation
  – Two large bore(16G)
  – 2 L Ringer’s lactate
     • Rapid responder: surgical evaluation necessary initially
     • Transient response: ongoing loss/inadequate resuscitation, rapid surgical
     • 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, (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

Liver Trauma

• Conservative: paradigm shift
  – Before 1993, routine operative treatment
  – Between 1993 - 1994, selective non operative
  – Between 1994 - 1998, non operative
    management standard practice
       Conservative treatment
• Avoids laparotomy and complications of
• 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
•   Explore and drain
•   Distal pan/splenectomy
•   Recognise duodenal injury
•   Refer or call for help if needed
    – Whipple’s resection (SGRH, < 5% mortality)
• Conservation
  – Key is to be able mobilise spleen outside the
• 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
  – 1983: Stone abbreviated laparotomy, 11/17 survivors
• Rotundo: damage control surgery, 1990s
            The lethal triad

 Bleeding              coagulopathy

Acidosis hypothermia
• Fluids needed for resuscitation
• Exposure of body
• Large incision and long duration of
• 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
• Lactate production from anaerobic
• 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
• Dilution worsens coagulopathy
• Dilution and hypothermia additive
• Acidosis worsens coagulopathy
    Damage control procedure
• 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
•   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
• 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
• 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
• Important to recognise when to stop
  operating: stop the bleeding and deal with
• 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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