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น ำเสนอวันพุธที่ 28 มีนำคม 2555
จัดท ำโดย Ext.สรวิศ บุญญฐี
Topic Review :Penetrating abdominal Trauma
Learning Topic
Anatomy of abdomen
Mechanism of Injury
Management
Anatomy of Abdomen
Anat
omy
of A
bdom
en
InternalThoracic
cavity
Peritoneal
cavity
Retro -
peritoneal
space
Pelvic
cavity
ExternalAnterior
abdomenFlank Back
Thoraco -
abdominal
Anatomy of Abdomen (External)
Anatomy of Abdomen (Internal)
Mechanism of Injury
• Compression
• Crushing
• Shearing
• Deceleration
(fixed organs)
Blunt
• Laceration / low
energy
• Kinetic energy /
high energy
Penetrating
Mechanism of Injury
Mechanism of Injury
• Minimal symptom : high negative explore.
• Complication from surgery : 22 %
• Selective management.
Stab wound
• Higher Risk for internal organ injury
• Risk of visceral organ injury : 90%
• Suggest to operate.
Gunshot wound
Mechanism of Injury
• Many small bullets
• Severity depend on distance of victim from weapon.
• Type I : Long range. ( > 7 yards )
• Subcutaneous. No need for operation
• Type II : Short range. ( 3-7 yards )
• Need operation & suture. Mortality 20 %
• Type III : Very short range. (< 3 yards )
• Large defect , Need operation, Mortality rate 85-90 %
Shotgun wound
Management
Surgery without Investigation
Penetrating injury
Gun shot wound
(not tangential)
Penetrating wound
with
Peritonitis
Hypotension
Evisceration
Penetrating abdominal trauma
Anterior abdomen Flank or back
Stab woundGunshot wound
Local explore wound
Observe
CT ScanTangential wound ?
ObserveDPL or
Dx Laparo DPL or
OR
Circulatory status
Surgical abdomen
Stable
Unstable OR
OR
OROR
No
No
Yes
Yes+ve+ve-ve -ve
Penetrating Thoracoabdominal TraumaAcute phase
ResuscitateATLS protocols
Insert NG if nocontraindications
CXRNormal Abnormal
Indications for
surgical intervention present
(ie: Thoracotomy orLaparotomy)
Indications for
surgical intervention present
(ie: Thoracotomy orLaparotomy)
No indication for
surgical intervention
No indication for
surgical intervention
OR
Examine diaphragm
Right side Left side
Admit
ObserveRepeat CXR
Laparoscopy
or thoracoscopy
Laparoscopy
or thoracoscopy
OR
Examine diaphragm
Consider CTObserve
Right side Left side
Investigation
Diagnostic peritoneal lavage
Diagnostic Laparoscope
Local Wound Exploration
Diagnostic peritoneal lavage
- performed after gastric and urinary bladder decompression
- Aspirate the content from intraabdomen.
If aspiration is negative : lavage.
Put in isotonic solution
Lactated Ringer’s solution or normal saline
A liter in adult and 20 ml/kg in children
Mixing of the lavage fluid.
Diagnostic peritoneal lavage
Criteria for Diagnostic from DPL
At least 10 ml of gross blood
RBC count at least 100,000 / mm3
WBC count at least 500 / mm3
Amylase > 19 IU/L
ALP > 2 IU/L
Bilirubin level > 0.01 mg/dL
Food particle , fecal material , bile , bacteria
Fluid come from NG , urinary catheter , ICD
Diagnostic peritoneal lavage
False positive :
• Bleeding from the lavage site
• Injury of the omentum or mesentery by lavage catheter
False negative :
• Faulty catheter placement
• Compartmentalization of the abdomen by adhesion
• Bleeding is slow and perform DPL too early
• Rupture diaphragm
Diagnostic Laparoscope
Useful in :
Thoracoabdominal wounds.
Tangential GSW
Equivocal stabbed wound
Advantage : Direct examination of intraperitoneal structure
Local Wound Exploration
Evaluation the depth of the wound.
Determine whether they penetrate the peritoneum.
Usually performed in the wound that located
anterior to the anterior axillary line.
? Question
Reference
• Schwartz's Principles of Surgery, 9th Edition, 2010
• Sabiston Textbook of Surgery, 17th Edition, 2004
• Tintinalli's Emergency Medicine, 7th Edition, 2011
• Rosen’s Emergency Medicine 7th Edition, 2010
• ATLS Advanced Trauma Life Support for Doctors 8th
Edition, 2008
• Evaluation of Abdominal Trauma, American Collage of Surgeons, 2003
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