Basic ScienceAbdominal Trauma

September 20th, 2009

TraumaEvaluation of the patient

Solid Organ Injury Hollow Viscus Injury

Potpourri

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A perforating injury to the stomach could be managed successfully

with this approach.

x

Stomach injuries

• Double layer running suture line or even stapling of defects would be appropriate

• If the injury includes the nerves of Laterjet of both vagus nerves then a drainage procedure should be performed

x

This would be considered appropriate treatment of an extraperitoneal rectal

injury.

x

Rectal injuries

• Assessment with proctoscopy, CT scan with rectal contrast

• Pre-sacral drainage and diversion with loop sigmoid ostomy

X

A 27 y/o male suffers a GSW to the abdomen with an isolated colon injury

on the right side. He is hemodynamically stable in the OR.

This is the procedure of choice.

X

Colon injuries

• 3 ways to approach treatment: primary repair, repair with ostomy, exterioirized repair

• Primary repair appropriate if there is limited fecal contamination, patient is stable without massive transfusion requirements

x

This is the preferred management of duodenal hematoma

X

Duodenal Hematoma

• Common in children with blunt abdominal injury

• Conservative management with NG decompression and TPN for 7 to 14 days

• If no resolution with conservative management evacuation is less morbid than bypass procedure

x

This patient was involved in a rollover ATV accident and has this diagnosis on

CXR

X

Diaphragmatic Rupture

• This should be promptly repaired through an abdominal incision

• Chronic diaphragmatic hernia should be approached through the chest

• NG tube above the level of the diaphragm is pathognmonic for this injury

• Repair with running monofilament suturex

F.A.S.T.

• Focused abdominal sonogram in trauma• 4 windows assessed, pericardial, liver, spleen

and bladder• exquisitely sensitive for detecting

intraperitoneal fluid collections larger than 250 mL

x

The acronym F.A.S.T. stands for this procedure.

x

Prior to removing a patient’s kidney secondary to traumatic injury you should to see if they

have one of these.

x

Another kidney

• 95% of blunt renal injuries are managed non-operatively

• Explore expanding or pulsatile hematomas during blunt traumas and all penetrating injuries

x

This type of suture should be used for the repair of biliary injuries.

x

Monofilament absorbable suture

• Permanent suture can lead to stone formation• Primary repair generally not feasible, CBD

injury can be repaired over T-tube or with Roux-enY choledochojejunostomy with interrupted sutures 6-8 total

• Gallbladder injuries repair with running monofilament suture or perform cholecystectomy

x

These vaccines should be given after splenectomy.

x

Splenectomy

• Pneumococcus, Meningococcus, Hib• Post-splenectomy sepsis up to 50% mortality

x

This is the incision of choice for exploration of the abdomen for a

trauma

x

Vertical midline incision

• This will allow appropriate access to all organs• Open from xyphoid to pubis and don’t be

afraid to use the knife (it’s faster than the bovie!)

x

In a post-op trauma patient in the ICU with decreased urine output and

bladder pressure of 25mmHg this is the procedure that will alleviate their

condition.

X

Abdominal Compartment Syndrome• Accumulation of blood and edema in the

abdomen will lead to increased abdominal compartment pressures

• Increased airway pressures, decreased cardiac output, decreased venous return start to develop at pressures >15mmHg

x

Access to the lesser sac and the supraceliac aorta can be gained through this anatomic structure.

x

Aortic control

• Mobilize the left hepatic ligament, open the gastrohepatic ligament, the NG tube can be palpated to identify the esophagus and used to retract it laterally, the aorta can be clamped here, sometimes it is necessary to take down the right crus of the diaphragm

• Alternatively a left anterior thoracotomy with clamping of the thoracic aorta can be performed if the patient rapidly decompensates

x

This is the amount of time that you could safely employ a Pringle

maneuver.

x

Liver hemorrhage

• Pringle maneuver involves clamping of the portal triad

• Has been reported safe up to one hour• Will quickly distinguish between arterial or

portal vein bleeding and hepatic vein/retrohepatic vena cava bleeding

x

According to Dr. Adams the spleen belongs in this anatomical position.

x

“The spleen is a midline organ”

• Divide the ligaments between the spleen and the splenic flexure, rotate the spleen up and out dividing the peritoneal reflection inferiorly

• Hilar and severe parychemal inujuries require splenectomy

• Don’t attempt to salvage the spleen if the patient is unstable or coagulopathic

x

RBCs >100,000/uL, presence of vegetable matter/bile/fecal matter are

indicators for intrabdominal injury with this procedure.

X

Diagnostic Peritoneal Lavage (DPL)

• Infraumbilical approach unless pelvic fracture present, then go supraumbilical

• Initial aspiration of 10cc blood is a positive test

• Useful in patients whom you suspect an injury, FAST is negative and are hemodynamically stable

x

This patient suffered a stab wound to the abdomen. The most appropriate next step in evaluation would be this.

X

Penetrating Injuries

• Stab wounds to the abdomen or flank may be locally explored at the bedside if there are no peritoneal signs, normal FAST, and the patient is hemodynamically stable

• GSW basically always go to the OR• Obvious peritoneal penetration goes to the

OR

x

This device can be used to manage retroperitoneal bleeding.

X

Schrock Shunt

X

A 36 y/o male is kicked in the stomach by a horse. He is hemodynamically

stable with normal H&H but a grossly positive F.A.S.T. scan. What is the

diagnosis?

X

Bladder rupture

• Grossly positive F.A.S.T. with blunt trauma and no hemodynamic instability

• Usually located at the dome of the bladder• Repair in 2-3 layers: mucosa, muscle layer,

serosa• Leave foley for one week

X

This is the term coined for initial management of sever traumatic

injuries followed by stabilization and resucitation in the ICU.

X

Damage Control Laparotomy

• temperature <35°C (95°F), • arterial pH <7.2, • base deficit <15 mmol/L (or <6 mmol/L in

patients over 55 years of age) • INR or PTT >50% of normal.

X

This is the most commonly injured solid organ in blunt trauma.

X

Liver• Admit to the SICU with frequent hemodynamic monitoring,

determination of hematocrit, and abdominal examination. • Absolute contraindication to nonoperative management is

hemodynamic instability. • Factors such as high injury grade, large hemoperitoneum,

contrast extravasation, or pseudoaneurysms may predict complications or failure of nonoperative management.

• The indication for angiography to control hepatic hemorrhage is transfusion of 4 units of RBCs in 6 hours or 6 units of RBCs in 24 hours without hemodynamic instability.

X