MEDICAL MANAGEMENT OF ABDOMINAL TRAUMA

LUIS H. TELLO MV, MS, DVM, COS Portland Hospital “Classic”

International Medical Advisor Banfield Pet Hospital

ABDOMINAL TRAUMA

• 70-80% of multiple trauma patients

• 55% of motor vehicle accidents

• Undiagnosed in human trauma patients

• 40% of them are asymptomatic

• The most frequent are • BLUNT TRAUMA

• PENETRATING TRAUMA

MASSIVE ABDOMINAL BLUNT TRAUMA

ABDOMINAL TRAUMA • PHYSIOPATHOLOGY

– Combining forces :

• Compression

• Extension

• Separation

– Kinetic energy is transferred to abdominal organs

– The transmitted energy overcomes organ resistance

ABDOMINAL TRAUMA

• PHYSIOPATHOLOGY – The energy dissipated in the abdomen is:

KE= MV2 2

KE: Kinetic Energy M : Mass V : Velocity

ABDOMINAL TRAUMA • ASSOCIATED CLINICAL SIGNS:

– Abdomen Haematoma

– Perineal Haematoma (Retroperitoneal)

– Abdominal tenderness (Pain)

– Hemodynamic instability (Hemorrhage)

– Pelvic fractures - Caudal ribs

– Lumbar spine injuries

– Abdominal distention

ABDOMINAL TRAUMA

ABDOMINAL TRAUMA

• ABDOMINAL

DISTENTION:

– Sensitive parameter in

humans

– Associated to pain

– No informatio1n in

Veterinary Medicine

– Each inch of increment in

abdominal perimeter:

500cc of free

intraabdominal blood

Massive Abdominal Trauma

First dogs used for hunting

Traumatic Hemobadomen

…almost always is better to go to Sx… with the exception of when is not !!

Hemoabdomen: Epidemiology • Incidence 11 %

• 71 % are closed trauma cases,

• 29% open or penetrating

• 20 % of patients that are moved to Sx have lesions NO DETECTED PREVIOUSLY

• Humans: 40% is asymptomatic

Cats may have spontaneous hemoabdomen!

• JVECCS 2010, Drobatz, et al • Sixteen cases of feline, non-traumatic hemoperitoneum were

evaluated retrospectively.

• The causes of hemoperitoneum were hepatic neoplasia (31%), hepatic necrosis (19%), hepatic amyloidosis (13%), non hepatic neoplasia (13%), hepatopathy (6%), hepatic rupture (6%), necrotic/hemorrhagic cystitis (6%), and ruptured bladder (6%).

Trauma de abdomen

Anatomy:

Hemoabdomen

Types of trauma

• Closed

• Open

Penetranting Trauma

• Bullets, arrows, impalement, bites,

• Caudal lesions in the thorax may be abdominal

Closed abdominaltrauma: Approach

• PE is difficult and equivocal

• Key: 5 signs – Temperature

– Pulse

– Respiratory rate

– Blood Pressure

– Pain Score

Goals during initial assessment

Determine:

• There is an intraabdominal lesions

• Require medical or surgical Tx

• Find out signs of the TRIADE of DEATH – ACIDOSIS

– HYPOTHERMIA

– COAGULOPATHY

ABDOMINAL TRAUMA

• DIAGNOSTIC

PROCEDURES:

– ABDOMINOCENTESIS

– PERITONEAL LAVAGE

– ABDOMINAL

ECOTOMOGRAPHY

– ABDOMINAL

RADIOGRAPHY

– C.A.T. SCAN

ABDOMINAL TRAUMA

• ABDOMINOCENTESIS:

ABDOMINAL TRAUMA

• ABDOMINOCENTESIS:

– 20-22G Needle or Butterfly

catheter+syringe

– Medium line caudal to umbilical scar

– Get inside, infusing saline 0,9%

– Negative: 4 quadrants puncture

– Negative: peritoneal lavage

ABDOMINAL TRAUMA

• PERITONEAL LAVAGE:

– 20 - 22 G needle or butterfly catheter

– Central medium caudal to umbilical scar

– Infuse 20 ml/Kg warm saline NaCl 0,9%

– Rotate or walk the patient

– Obtain a few ml for evaluation

ABDOMINAL TRAUMA

• PERITONEAL LAVAGE : evaluation

– PCV

– PROTEINS

– CITOLOGY

– BUN - CREATININ

– BILIRRUBIN

– “BOYSCOUT” TEST

ABDOMINAL TRAUMA

• BOY SCOUT TEST:

– PUT A DROP OF PERITONEAL LAVAGE

FLUID ON A MICROSCOPE SLIDE

– HEAT TO DIRECT FLAME

– AMMONIA RELEASE? URINE !!

– SCOUTS PUT OUT FIRES WITH URINE

ABDOMINAL TRAUMA

• POSITIVE LAVAGE:

HEMOPERITONEUM

– PCV > than peripherical

– Spleen has a higher PCV

than blood

– The peritoneum absorbs

water and electrolytes

– More than 100.000

erythrocytes/ml

– More than 500 leukocytes/ml

– Can it be read through the

tube??

HEMOPERITONEUM

MANY

POINTS

OF VIEW!!!!

Lab Data Base

• Hct y Hb

• Glycemia

• Creatinine

• Ca - Mg

• CPL

• Proteines

• UA

• Coagulation profile

• Blood gases- electrolytes

Images

• Radiographs

• Limited value: serosal detail, free gas

• Hernias

• Evidence of bone/joint/soft tissue lesions

Trauma Abdomen

You may think on…...

Pneumocystography Contrast studies

Trauma abdomen

Hemoabdomen

Pneumoperitoneo

Radiographs

JAVMA. 2004 Oct 15;225(8):1198-204

Evaluation of focused assement with sonography for trauma protocol to detect free abdominal fluid in dogs involved in motor vehicle accidents

Boysen S, Rozanski E, Tidwell ,A

• 4 points

Ultrasound: FAST

Tap the abdomen

• Easy, fast, cheap

• High percentage of false negatives

• Should be more than 5 ml/Kg of free fluid

Abdomen Trauma

Abdominal centesis: 4 quadrants

DPL: Diagnostic

Peritoneal Lavage

Negative Tap

Introduce 20ml/kg warm saline

Very sensitive

Collect fluid in tubes: with and without EDTA

Do not use for

Retroperitoneal lesions,

Pregnant

Dilated GI

Materials

Mini Laparotomy

Entonces….cortamos o no?

Gross examination

RED: Hemorrhage

GREEN:Gallbladder – Biliary tract

YELLOW: Urinary tract

BROWN” GI tract

So….cut or not? • The key seems to be on the patient

– No response to Tx

– Worsening hypotension

– Mentation worsening

– Drop on the Hct (20%)

– If you are not sure…..

No Sx Tx of HEMOBANDOMEN)

• FLUID Tx (NO EXCESSIVELY AGGRESSIVE)

• PLASMA – Coagulation factors

• Pain management

• Sedation

• Oxygen

• ICU MONITORING

Sx: Damage control

Control of hemorrhage

Explore

Control of contamination

Packing

Fast closure

• Pringle maneuver

Hemorrhage control

Packing

Post Sx

• Fluids, Atb, Nutrition

• Check Hct, Proteines, Albumine

• Monitor Blood Pressure

• Monitor ECG

• Monitor Urine production

• DO NOT FEEL SAFE BEFORE 72 HOURS POST SX

UROPERITONEUM

UROPERITONEUM • Massive rupture is frequent in blunt

trauma with full bladder

• It can be diagnosed with contrasted

X-rays :

• Excretion Nephrogram

• Contrasted Cystogram

• Pneumocystogram

UROPERITONEUM • Massive rupture is frequent in blunt

trauma with full bladder

• It can be diagnosed with contrasted

X-rays :

• Excretion Nephrogram

• Contrasted Cystogram

• Pneumocystogram

UROPERITONEUM • SURGICAL THERAPY

THANKS