Trauma presentation Dec 2009

8/7/2019 Trauma presentation Dec 2009

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Minimally Invasive SurgeryMinimally Invasive Surgery

in Trauma and Gunshot Woundsin Trauma and Gunshot Wounds

A. Rakhlin, M.D.A. Rakhlin, M.D.Department of SurgeryDepartment of Surgery


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Two uses: slim and noneTwo uses: slim and none

Blunt traumaBlunt trauma Hemodynamically stable patientsHemodynamically stable patients

stable for CTs as well as interventional radiologic proceduresstable for CTs as well as interventional radiologic procedures

Hemodynamically unstable patientsHemodynamically unstable patients Need laparotomy, not laparoscopyNeed laparotomy, not laparoscopy

Penetrating traumaPenetrating trauma Knife woundsKnife wounds

Limited application for diagnostic laparoscopyLimited application for diagnostic laparoscopy judge penetrationjudge penetrationinto abdominal cavity (esp in chest knife wounds), run the bowelinto abdominal cavity (esp in chest knife wounds), run the bowel

BulletsBullets Usually damage is too widespread for laparoscopyUsually damage is too widespread for laparoscopy


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Gunshots and InjuriesGunshots and Injuries


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GUNSHOT INJURIESGUNSHOT INJURIES

WOUNDING VARIABLESWOUNDING VARIABLES

BULLET SIZEBULLET SIZE

BULLET VEL

OCITY

BULLET VEL

OCITY

BULLET SHAPEBULLET SHAPE

BULLET SPINBULLET SPIN

BULLET TRAVEL DISTANCEBULLET TRAVEL DISTANCE

TYPE OF TISSUE STRUCKTYPE OF TISSUE STRUCK


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KE = MVKE = MV22

High VelocityHigh Velocity

>2000 fps>2000 fps

Low VelocityLow Velocity


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YAW (non-rifled)

TUMBLE

DEFORMATION

FRAGMENTATION


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TISSUE CHARACTERISTICTISSUE CHARACTERISTIC

1.1. LESS DAMAGE WITH:LESS DAMAGE WITH:

ELASTICITY AND DENSITYELASTICITY AND DENSITY(EXAMPLE: LUNGS)(EXAMPLE: LUNGS)

2.2. MORE DAMAGE WITH:MORE DAMAGE WITH:

ELASTICITY AND DENSITYELASTICITY AND DENSITY(EXAMPLE: LIVER; SPLEEN;(EXAMPLE: LIVER; SPLEEN;

BRAIN)BRAIN)


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Sonic Pressure WaveSonic Pressure Wave

Preceeds the bulletPreceeds the bullet

Very short durationVery short duration

Usually no significant damageUsually no significant damage Permanent CavityPermanent Cavity

Tissue directly destroyed by the bulletTissue directly destroyed by the bullet

Possible to have small entry wound and large permanentPossible to have small entry wound and large permanentcavitycavity

Temporary CavityTemporary Cavity

Transient expansion of tisssues as bullet releases its kineticTransient expansion of tisssues as bullet releases its kineticenergyenergy

Can be up to 30 times the size of bulletCan be up to 30 times the size of bullet

GUNSHOT INJURIES: 3 phasesGUNSHOT INJURIES: 3 phases


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Additional considerationsAdditional considerations As the bullet enters, it creates negative pressureAs the bullet enters, it creates negative pressure

Pulls contaminated residue from outsidePulls contaminated residue from outside

Especially wadding in shotgun injuriesEspecially wadding in shotgun injuries Missile EmbolizationMissile Embolization if no exit wound foundif no exit wound found xx--

ray surveyray survey

Lead PoisoningLead Poisoning

Esp if bulletEsp if bulletis in synovialis in synovial

fluidfluid


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Extremity gunshot injuries:Extremity gunshot injuries:

vascularvascular Varies from intimal disruption to completeVaries from intimal disruption to complete

lacerationlaceration

Vessel may temporarily contractVessel may temporarily contract Partial laceration will not contractPartial laceration will not contract extensive bloodextensive blood

losslossLocation of wound Incidence (%)

Lateral thigh 1

Medial or posterior thigh 79Popliteal fossa 910

Calf or leg 1822

Upper arm or shoulder 910

Medial or posterior upper arm 68

Forearm or antecubital fossa 1722


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Extremity gunshot woundExtremity gunshot wound

injuries: Vascularinjuries: Vascular InvestigationsInvestigations

Physical examPhysical exam pulses, blood pressure differential.pulses, blood pressure differential.

10% of patients with normal exam have occult vascular10% of patients with normal exam have occult vascularinjuryinjury

High index of suspicionHigh index of suspicion angiogramangiogram

May reveal intimal flaps, other injuriesMay reveal intimal flaps, other injuries

Low threshold for fasciotomiesLow threshold for fasciotomies

Time to treatmentTime to treatment

6 hrs of ischemic time6 hrs of ischemic time

Temporary cavityTemporary cavity extensive muscle damageextensive muscle damage


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Extremity gunshot wounds:Extremity gunshot wounds:

neurological damageneurological damage 7070--90% recovery within 3 months if:90% recovery within 3 months if:

NeuropraxiaNeuropraxia stretching, no actual disruption of the nervestretching, no actual disruption of the nerve

AxonotmesisAxonotmesis disruption of axon and myelin sheaths, butdisruption of axon and myelin sheaths, but

with preservation of connective tissuewith preservation of connective tissue Generally 1 mm/dayGenerally 1 mm/day

NeurotmesisNeurotmesis complete severance of nervecomplete severance of nerve 25% of patients recover after nerve repair25% of patients recover after nerve repair

Late sequalaeLate sequalae reflex sympathetic dystrophyreflex sympathetic dystrophy Pain, swelling, vasomotor dysfunction in extremityPain, swelling, vasomotor dysfunction in extremity

Treatment varies from sympathetic blocks to acupunctureTreatment varies from sympathetic blocks to acupuncture Rates of cure variableRates of cure variable


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Gunshot Wounds to AbdomenGunshot Wounds to Abdomen

Maryland medical journalMaryland medical journal -- 18841884

\\Professor Kocher of Berne declares that, considering theProfessor Kocher of Berne declares that, considering the

impossibility of recovery in cases of gunimpossibility of recovery in cases of gun--shot wounds to stomachshot wounds to stomachwhen active measures are not taken, it is the duty of thewhen active measures are not taken, it is the duty of the

surgeon to perform laparotomy whenever injury of this kind issurgeon to perform laparotomy whenever injury of this kind is

suspected.[suspected.[ Still true in 2009Still true in 2009


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Gunshot wound: abdomenGunshot wound: abdomen

Unless a rare caseUnless a rare case do not pass Go, do notdo not pass Go, do notcollect $200collect $200 proceed directly to ORproceed directly to OR

Rare casesRare cases BB guns, tangential wounds to flankBB guns, tangential wounds to flank CT scan, check for free air, free fluid, considerCT scan, check for free air, free fluid, consider

contrast per rectum to r/o colon injurycontrast per rectum to r/o colon injury

Abdomen starts at nipplesAbdomen starts at nipples

Hence earlier remark on utility of laparoscopy inHence earlier remark on utility of laparoscopy inchest injurychest injury

30% of GSW to hips are associated with intraabd30% of GSW to hips are associated with intraabdinjuryinjury


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Gunshot wounds: In the ORGunshot wounds: In the OR

Complete survey, prep from neckComplete survey, prep from neckto thighs, left arm outto thighs, left arm out Pack four quadrantsPack four quadrants

Damage control laparotomyDamage control laparotomyin unstable patientin unstable patient Close all visceral injuriesClose all visceral injuries

Pack all solid organ injuriesPack all solid organ injuries May perform quick splenectomyMay perform quick splenectomy

Pack retroperitoneumPack retroperitoneum

Get out for ICU resuscitationGet out for ICU resuscitation

Deadly triadDeadly triad Hypothermia, coagulopathy,Hypothermia, coagulopathy,

acidosisacidosis


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Abdomen wont close?Abdomen wont close?

Abdominal compartment syndromeAbdominal compartment syndrome

Extensive damage and resuscitationExtensive damage and resuscitation

Open abdominal dressingOpen abdominal dressing VAC, Bogota bag, vicryl meshVAC, Bogota bag, vicryl mesh

VACVAC


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Bogota bagBogota bag


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Zipper closureZipper closure


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Individual organ treatmentIndividual organ treatment

IntestinesIntestines Stomach, small bowelStomach, small bowel freshen up edges, primaryfreshen up edges, primary

repair, resection if multiple wounds in closerepair, resection if multiple wounds in close

proximity to each otherproximity to each other Large bowelLarge bowel conservativeconservative diversion, ostomydiversion, ostomy

SpleenSpleen splenectomy, splenorrhaphy if fesiblesplenectomy, splenorrhaphy if fesible

LiverLiver dreaded injury. Treatment depends ondreaded injury. Treatment depends onintraop findingsintraop findings deep sutures, hepatectomy,deep sutures, hepatectomy,arterial devascularization, venoarterial devascularization, veno--venous bypassvenous bypass


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Individual organ treatmentIndividual organ treatment

RetroperitoneumRetroperitoneum

UpperUpperretroperitoneumretroperitoneum

Great vessels (thatsGreat vessels (thatswhy left arm waswhy left arm wasabducted),abducted),

Duodenum, PancreasDuodenum, Pancreas

Books have beenBooks have beenwritten on duodenalwritten on duodenal

and pancreaticand pancreaticinjuries.injuries.


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Duodenal ExclusionDuodenal Exclusion


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QuestionsQuestions??

Documents

Trauma presentation Dec 2009