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Case Report
Chirurgia Generale Prof. A.L. Gaspari
a.a. 2009/2010
Case Presentation Monday, 6.00h….On the way home from a night of
bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the light @ 90 km/h...in Viale di Tor
Vergata. As usual, being drunk, the driver walks out of his car
without a scratch. (...except for scratching his head in disbelief!)
The passenger…not so lucky!
Case Presentation Monday, 6.00h….On the way home from a night of
bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the light @ 90 km/h...in Viale di Tor
Vergata. As usual, being drunk, the driver walks out of his car
without a scratch. (...except for scratching his head in disbelief!)
The passenger…not so lucky!
He’s all yours!...good luck!
Case Presentation Moday, 6.00h….On the way home from a night of
bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the light @ 90 km/h...in Viale di Tor
Vergata. As usual, being drunk, the driver walks out of his car
without a scratch. (...except for scratching his head in disbelief!)
The passenger…not so lucky!
He’s all yours!...good luck!...(TO THE PATIENT!!!!)
What to do FIRST?
What to do FIRST? ATLS!!!
What to do FIRST? ATLS!!!
PRIMARY SURVEY & RESUSCITATION: “ABCDE” rule
1/00 9
PRIMARY SURVEYPRIMARY SURVEY
A :A :B :B :C :C :D :D :E :E :
1/00 10
PRIMARY SURVEYPRIMARY SURVEY
A :A : Airway with cervical spine protect.B :B :C :C :D :D :E :E :
1/00 11
PRIMARY SURVEYPRIMARY SURVEY
A :A : Airway with cervical spine protect.B :B : BreathingC :C :D :D :E :E :
1/00 12
PRIMARY SURVEYPRIMARY SURVEY
A :A : Airway with cervical spine protect.B :B : BreathingC : C : Circulation --control external bleeding.D :D :E :E :
1/00 13
PRIMARY SURVEYPRIMARY SURVEY
A :A : Airway with cervical spine protect.B :B : BreathingC : C : Circulation --control external bleeding.D :D : Disability or neurological statusE :E :
1/00 14
PRIMARY SURVEYPRIMARY SURVEY
A :A : Airway with cervical spine protect.B :B : BreathingC : C : Circulation --control external bleeding.D :D : Disability or neurological statusE :E : Exposure (undress) & EEnvironment (temp control)
1/00 15
PRIMARY SURVEYPRIMARY SURVEY
If there is evident bleeding, what to do If there is evident bleeding, what to do IMMEDIATELY??? IMMEDIATELY???
1/00 16
PRIMARY SURVEYPRIMARY SURVEY
If there is evident bleeding, what to do If there is evident bleeding, what to do IMMEDIATELY???IMMEDIATELY???
control bleeding by direct pressure!!!!!!
1/00 17
PRIMARY SURVEYPRIMARY SURVEY
If there is evident bleeding, what to do If there is evident bleeding, what to do IMMEDIATELY???IMMEDIATELY???
control bleeding by direct pressure!!!!!!(or at least, try!….)
1/00 18
ResuscitationResuscitation
Airway - definite airway if there is any doubt about the pt’s ability to maintain airway integrity.
Breathing /Ventilation/Oxygenation- every injured pt should received supplement oxygen
Circulation- control bleeding by direct pressure or operative intervention- minimum of two large caliber IV should be established- pregnancy test for all female of child bearing age.- Lactated Ringer is preferred & better if warm
Case Presentation
25 year old maleCar-accident, trauma on his left side
Left chest pain & no deformityLeft shoulder pain (!!!)
A good air entry
Case Presentation
25 year old maleCar-accident, trauma on his left side
Left chest pain & no deformityLeft shoulder pain (!!!)
A good air entry B Rt chest pain and bruising
Case Presentation
25 year old maleCar-accident, trauma on his left side
Left chest pain & no deformityLeft shoulder pain (!!!)
A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0 , EKG normal
Case Presentation
25 year old maleCar-accident, trauma on his left side
Left chest pain & no deformityLeft shoulder pain (!!!)
A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0 , EKG normal D GCS 15
Case Presentation
25 year old maleCar-accident, trauma on his left side
Left chest pain & no deformityLeft shoulder pain (!!!)
A good air entry, spO2 98% B Left chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0, Ht 46 , EKG
normal D GCS 15 E Chest and flank abrasions LEFT SIDE!!
Case Presentation
Transfer to PTV emergency department
TRIAGE ???
Case Presentation
Transfer to PTV emergency department
TRIAGE ??? Patient general condition Age Type of trauma Associated injuries
Case Presentation
Transfer to PTV emergency department
TRIAGE ??? Patient general condition Age Type of trauma Associated injuries
RED : Most critical injuryYELLOW : Less critical injuredGREEN : No life or limb threatened injuryBLACK : Death or obviously fatal injury
Case Presentation
Transfer to PTV emergency department
TRIAGE ??? Patient general condition Age Type of trauma Associated injuries
RED : Most critical injury
Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG
monitoring
Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG
monitoringevery hour or continuous monitoring !!!!!
Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG
monitoringevery hour or continuous monitoring
Ventilatory rate and Pulse-oximetry
Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG
monitoringevery hour or continuous monitoring
Ventilatory rate and Pulse-oximetry
Inspection
Physical ExaminationAbdominal Trauma Evaluation BP and Pulse trend, ECG monitoring
every hour or continuous monitoring Ventilatory rate and Pulse-oximetry Inspection
Seat belt mark Skin lacerations Previous surgery scar
PHYSICAL EXAMINATIONAbdominal Trauma
Physical examination unreliable Head trauma Spinal cord injuries Alcohol intoxication Use of illicit drugs Injuries to adjacent structure Significant amount of blood present Analgesia
Diagnostic MethodsAbdominal Trauma
Physical examination Bruises, abrasion over the abdomen Abdominal pain or tenderness Absent bowel sounds Unexplained hypotension
P/E equivocal or misleading.!!! Peritoneal sign falsely negative in 40% Peritoneal sign falsely positive in 20%
10% of all injuries are initially overlook
WHY?
Physical ExaminationAbdominal Trauma Evaluation
Auscultation
Physical ExaminationAbdominal Trauma Evaluation
Auscultation Chest ventilation Peristaltic activity
Physical ExaminationAbdominal Trauma Evaluation
Auscultation Chest ventilation Peristaltic activity
Palpation
Physical ExaminationAbdominal Trauma Evaluation
Auscultation Chest ventilation Peristaltic activity
Palpation Rebound tenderness Guarding Pelvic instability Digital pression for fractures assessment (ribs)
Physical ExaminationAbdominal Trauma Evaluation
Rectal examination (?)
Physical ExaminationAbdominal Trauma Evaluation
Rectal examination (?) Prostate Rectal tone
PVC and vascular access Abdominal Trauma Evaluation
Peripheral Venous Catheter (PVC)
PVC and vascular access Abdominal Trauma Evaluation
PVC At least two 16-18 G (large caliber) Complete blood count and chemistry
and coagulation Blood cross-matching test
(independently by Hb at presentation!)
Resuscitation Abdominal Trauma Evaluation
Fluid therapy Initial fluid therapy at least 1-2 L for
adults Warm fluids Cristalloids or Colloids ???
Tube Insertion Abdominal Trauma Evaluation
Gastric tube….yes or no?
Tube Insertion Abdominal Trauma Evaluation
Gastric tube Relieves distention (stomach in CT
scan) If drunk or other altered mental
status Decrease risk of unattended
vomiting But can also induce it , risk of aspiration
!!!
Tube Insertion Abdominal Trauma Evaluation
Gastric tube Relieves distention (stomach in CT scan) If drunk or other altered mental status Decrease risk of unattended vomiting
But can also induce it , risk of aspiration !!!
Caution: Facial fracture/basilar skull fracture….(AFTER CT!!)
Tube Insertion Abdominal Trauma Evaluation
Urinary catheter
Tube Insertion Abdominal Trauma Evaluation
Urinary catheter Monitor urinary output
Tube Insertion Abdominal Trauma Evaluation
Urinary catheter Monitor urinary output
Caution!!! Inability to void retrograde Pelvic fracture urethrogram or
US! Blood at the meatus Scrotal/Peryneal Ecchymoses High riding prostate
Secondary Survey: imaging or OR? Abdominal Trauma Evaluation
Diagnostic Peritoneal Lavage (DPL) Ultrasound Scanning Computer Tomography Laparoscopy Immediate Laparotomy
DPL contraindications
Absolute Patient needs laparotomy
Relative Multiple previous operations Pregnancy (Third trimester)
DPL
Gross blood >10 ml Red cells >100,000 /mm3White cells >500 /mm3Amylase > 175u/dlgross GI contentsbacteria on gram stain
DPL Simple Fast Economical Reliable
accuracy 97.3 - 99.1 % false positive 0.2 - 1.4 % false negative 1.2 - 1.3 %
DPL Oversensitive
Lacks specificity
Fails to investigate Complication
rate
6-25% non-therapeutic
laparotomy rate!!!!!Source AmountContinuationRetroperitoneum
1 - 1.7 %
CT scan contraindications
Absolute Patient needs laparotomy Unstable patient
CT scan
Non-invasive Reliable Accuracy 91 - 98.3
% Sensitivity 60 - 85 % Specificity
100 %Delineate specific organ injuryHaemoperitoneum > 100mlAssesses the retroperitoneum
CT scan Need for transfer to scanner Need cooperative patient Complications related to contrast Ionizing radiation Cost + Time + Personnel Usefulness in hollow viscus and
dyapragmatic injury ?
Spleen Injuries
CT scan will save 70 % of spleen Observation X 72 hr Healing over 6 weeks
OPSI (overwhelming post Splenectomy infection) < 1% of splenectomy , increase in children
Postoperative Vaccination on VIII P.O.Which vaccination? And why?
Haemophilus Meningococcus Streptococcus
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
FAST Focused abdominal sonography for trauma
Reliability accuracy 86 - 97 % sensitivity 88 - 91.7 % specificity 94.7 - 99 %
Can detect 70 ml fluid
FAST Focused abdominal sonography for trauma
Safe (Non-invasive) Cheap Rapid Can be performed in resuscitation
area
Can be used to follow-up injuries being managed conservatively!!!!!!!
FAST Focused abdominal sonography for trauma
Training required Inter-observer variation Pitfalls: subcutaneous emphysema & gas
distension& morbid obesity Cannot determine type of fluid Inadequate detection of visceral
perforation Accuracy improves on repeated
scanning
LPS (?)
ONLY stable patient!!!!!!! No extensive intra-abdominal adhesions Suction irrigator catheter Angled laparoscopes Experienced laparoscopic surgeonCan be used as adjunct to CT and allows direct visualisation of injury allows assessment of whether there is ongoing
bleeding
LPS
Unsuitable for unstable patients Performed in operating room Difficulty to examine retroperitoneum
Choice?
DPL
CT Scan
USS (FAST)
Unstable patient to assess for blood and need for laparotomy
Stable patient to define site of injurymay permit non-operative Tx
Unstable patientRequires experience
X-Ray (in the past or complimentary) Abdominal Trauma Evaluation
1. C-spine 2. Chest AP
High association of chest injuries and abdominal injuries
Free air?
3. Pelvis
X-Ray (in the past or complimentary) Abdominal Trauma Evaluation
4. ? Urethrography (if hematuria)Keep good urinary output!
Better evaluated with CT scan
5. Spine fracture Chance Fracture 20% small bowel injuries
Scout Rx- like Free-air?
Skull base (coronal and axial)
Skull base fractures?
Spine lesion?
Skull base (coronal and axial)
Skull base fractures?
Spine lesion?
Thorax. Contusion? Pneumothorax? Ribs’ fractures? Hemothorax? Flail chest?
Thorax bases Pleural effusion? Food in stomach? Diafragmatic
hernia? Liver injuries?
CT abdomen :…si apprezzano multiple
lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
CT abdomen :…si apprezzano multiple
lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
CT abdomen :…si apprezzano multiple
lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
CT abdomen :…si apprezzano multiple
lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
CT abdomen :…si apprezzano multiple
lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
CT abdomen :…si apprezzano multiple
lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
CT abdomen Pancreatic lesion? Retroperitoneum?
Pelvic CT Pelvic fractures?
Pelvic CT Douglas pouch:
free intrabdominal fluid - heamoperitoneum?
Quantification of haemoperitoneum
Bladder?
Pelvic CT Urethra?
Abdominal US (postop control)
Case Presentation
Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch
BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade II
Case Presentation
Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch
BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade IISpleen injury II grade with stable vital signs:Observation OR Laparotomy ?
Case Presentation
Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch
BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade IISpleen injury II grade with stable vital signs:Observation OR Laparotomy ?......OR Laparoscopy?
Observation
The patient were OBSERVED clinically monitoring vital signs (Pa, HR, sPO2, diuresis).
Blood count and coagulation every 2 hours
Observation
Observation The patient remained clinically
stable but with valid diuresis BUT
Rapid decrease of Hb and Ht and coagulative function impairment: Hb 16 >11.6 Ht 45 > 34 INR 1.2 > 1.5
Observation
Observation
Surgical managment Laparotomy or Laparoscopy?
Surgical managment The patient underwent a diagnostic
laparoscopy and control of haemostasis.
Intraoperative finding: 800cc hemoperitoneum 2 splenic fractures
Surgical managment Haemostasis by
Coagulation Floseal Tabotamp
Lavage Large abdominal drainage
Postoperative Regular course (no fever, no wound
infection, no pleural effusion) Feeding on II P.O. Control: Abdominal US on VII P.O.
(patient refused abdominal CT scan) Hb at discharge 13.7, no need of
transfusion Discharge at VIII P.O. No need of vaccination! (OPSI)
Postoperative Absolute rest at home for 4 weeks:
avoid sports with physical contact, trauma, efforts….
RISK OF DELAYED RUPTURE OF THE SPLEEN!!!
Blood count @ 1 week Abdominal US @ 1 month Outpatient control @ 1 week and 1
month
Abdominal US (control) si documenta modica falda di
versamento perisplenico, che si dispone sino in pelvi. La milza presenta disomogenee caratteristiche ecostrutturali, in particolar modo in corrispondenza del suo margine laterale, con presenza nel suo contesto di immagine lineariforme da riferire verosimilmente ad area di fibrosi. In considerazione del dato anamnestico, necessario stretto monitoraggio dei parametri ematochimici ed eventuale nuovo controllo TC
Traumatic splenic lesion. Surgical Treatment
Traumatic splenic lesion. Classification
Blunt InjuryAbdominal Trauma
Spleen 25% Liver 15% Hollow viscus 15%
Ileum Sigmoid
Kidney 12%
Retroperitoneal 13% Mesentery 5%
Compression Crushing Shearing Avulsion
Investigations NEED TO HAVE AN HIGH INDEX OF SUSPICION
Depends on:
-Haemodynamic stability
-Other injuries present
Urgency to treat
Likelihood of intestinal injury Includes:
-Lab studies
-FAST Focused Assessment with Sonography for Trauma
-DPL Diagnostic Peritoneal Lavage -CT scan
- LPT/LPS?
Surgical managementA significant solid orgsan injuries will not
heal spontaneously and surgical intervention is the only acceptable approach for it
Pringle 1908
Once the diagnostic of Hemoperitoneum has been made, routinely the next goal of the surgeons will be to prepare the patient for surgery as rapidly and efficiently as possible
Sclafani 1991
Surgical management (cont’d)
Isolated severe blunt injury may be managed nonoperatively with better survival and less blood products use.
Grindlinger 1998
TIP Patient selectionType of Trauma
AgeAssociated injuries
Blunt Liver Trauma Protocol1998
C on serva tivem an ag em en t
< = 4 u n its /2 4 h r > 4 u n its /2 4 h r
L ive r In ju ryC lass 1 & 2
O R
L iver In ju ryC lass 3 ,4 ,5
assoc ab d . in j.
S tab leC T S can
O R
U n s tab le < 9 0L avag e
B P > = 1 0 0H R < = 1 0 0
G C S > 3
Outcome
Nonoperative Less blood mortality 15% Vs up to 63% LOS shorter
TIP decision to treat
is base on the patient stability
What’s New in Abdominal Trauma Diagnostic
Ct, U/S Laparoscopy its impact is coming
Therapeutic Nonoperative management
Spleen & liver Non operative for liver gunshot
“Damage control” laparotomy “Abdominal compartment syndrome”