CDR JOHN P WEI, USN MC MD4th Medical Battalion, 4th MLGBSRF-12

ABDOMINAL TRAUMA

ABDOMINAL TRAUMA

ABDOMINAL TRAUMA

•Types of abdominal trauma•Anatomical regions of the

abdomen•Initial care and diagnosis•Evaluation of patient with blunt

and penetrating trauma•Specific organ trauma•Surgery for injuries

BLUNT ABDOMINAL TRAUMA

Common causes of injury

• motor vehicle accidents• fall from heights• explosive blast injuries• physical assault

BLUNT ABDOMINAL TRAUMA

• Solid organ injuries including liver, spleen, kidneys, pancreas

• Rupture of hollow viscus including small and large intestine, stomach, esophagus, and bladder

• Vascular injuries• Bony fractures of pelvis and lumbar

spine

PENETRATING ABDOMINAL TRAUMA

• Mechanism of wounding and organ damage

• Stab wounds with knife or other instruments

• Gunshot wounds• Explosive injury with shrapnel or

secondary projectiles

PENETRATING ABDOMINAL TRAUMA

• Small and large intestine most commonly injured

• Lacerations of solid organs• Vascular injuries• Trajectory of penetrating instrument

and objects in its way

ANATOMY OF ABDOMEN

•True abdomen•Pelvic abdomen•Intrathoracic abdomen •Pelvis•Retroperitoneum

EVALUATION AND DIAGNOSISOF ABDOMINAL TRAUMA

EVALUATION AND DIAGNOSISOF ABDOMINAL TRAUMA

•Airway, Breathing, Circulation•History of injury and mechanism•Physical examination and vital signs•Radiologic studies•Laboratory testing

Resuscitation & management priorities of major abdominal trauma:

• Control airway and breathing

• Stabilize circulation with volume infusion or blood

• Hemorrhage control

• Nasogastric tube and urinary catheter if no pelvic fracture

Resuscitation & management priorities of major abdominal trauma:

• Control airway and breathing

• Stabilize circulation with volume infusion or blood

• Hemorrhage control

• Nasogastric tube and urinary catheter if no pelvic fracture

EVALUATION AND DIAGNOSIS OF ABDOMINAL TRAUMA

•HISTORY Blunt abdominal trauma

Penetrating abdominal trauma

•PHYSICAL EXAMINATION General physical examination Examination of the abdomen

•HISTORY Blunt abdominal trauma

Penetrating abdominal trauma

•PHYSICAL EXAMINATION General physical examination Examination of the abdomen

EVALUATION AND DIAGNOSISOF ABDOMINAL TRAUMA

Laboratory blood tests

Urinalysis Radiological Studies (Plain abdominal X-ray, CXR) Peritoneal lavage (DPL) FAST U/S of abdomen CT scan of abdomen

Laboratory blood tests

Urinalysis Radiological Studies (Plain abdominal X-ray, CXR) Peritoneal lavage (DPL) FAST U/S of abdomen CT scan of abdomen

EVALUATION AND DIAGNOSISOF ABDOMINAL TRAUMA

Peritonitis Hypotensive shock Evisceration of viscus Positive diagnostic (DPL) Determination of finding on FAST or CAT scan

Peritonitis Hypotensive shock Evisceration of viscus Positive diagnostic (DPL) Determination of finding on FAST or CAT scan

INDICATIONS FOR EMERGENT SURGERY

DAMAGE CONTROL SURGERY

•Prep surgical field from neck to knees and from flank to flank•Longitudinal incision form xiphoid to pubis•Cell saver to reinfuse autologous blood if possible•Urgent exploration with packing of all four quadrants of abdomen•Serial controlled examination of each quadrant and organ•Pack liver injuries and splenic injuries•Control vascular injuries•Close off perforated gastrointestinal tract•Examine retroperitoneal structures

DAMAGE CONTROL SURGERY

•Avoid hypotension, hypothermia, acidosis leading to coagulopathy

•Repair or ligate vascular injuries•Splenectomy if injured•Repair or resect intestines•Pack liver hemorrhage•Pack and leave open abdomen if necessary•Continue resuscitation and warming in ICU•Come back another day

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

Renal injuries on battlefield often complex injuries

If laceration and hematoma from blunt injury, may observe

If laceration from penetrating injury, may require nephrectomy to control bleeding

Need for drains after surgery

DAMAGE CONTROL SURGERY

Retroperitoneal injuries:Blunt traumaPenetrating traumaPotential vascular injuries

Zone 1Zone 2Zone 3

DAMAGE CONTROL SURGERY

• Pancreatic injuries• Duodenal injuries

DAMAGE CONTROL SURGERY

• Pancreatic injuries vary from simple contusions and lacerations to complex injuries of head of pancreas

• Complicated by concomitant duodenal injuries

• Strategy to control hemorrhage• Drainage of injuries• Secondary procedures to divert GI tract

DAMAGE CONTROL SURGERY

Diaphragmatic injury

DAMAGE CONTROL SURGERY

• Diaphagmatic injuries require surgical repair Diaphagmatic injuries require surgical repair to avoid herniation abdominal organs and to avoid herniation abdominal organs and compromise of pulmonary functioncompromise of pulmonary function

• Place chest tubes pleural cavity to control Place chest tubes pleural cavity to control pneumothoraxpneumothorax

DAMAGE CONTROL SURGERY

DAMAGE CONTROL SURGERY

• Surgical strategy depends on cause of intestine injury due to penetrating vs blunt vs explosive blast

• Degree of contamination• Small versus large bowel• Hemodynamic stability of patient• Suture repair• Stapled resection• No anastamosis if clinically unstable

SUMMARY

• Abdominal injury with potential for many Abdominal injury with potential for many organ systems at riskorgan systems at risk

• Blunt versus penetrating injuriesBlunt versus penetrating injuries• Surgery to repair damage and control Surgery to repair damage and control

hemorrhage from vascular structures and hemorrhage from vascular structures and organsorgans

• Damage control surgery to repair intestines Damage control surgery to repair intestines defined by battlefield conditionsdefined by battlefield conditions

• Stabilize and return for definitive repairStabilize and return for definitive repair