Diagnosis & Management of Acute Abdominal Trauma

1. Diagnosis & Management of Acute Abdominal Trauma Trauma Services Ottawa Hospital

2. Economic Burden ofInjury in Ontario 1996 • Injury death 2,844 • Hosp injuries 43,382 • Non hosp injuries 693,630 • Total injuries 739,856 • Partial perm. Disa.15,232 • Total perm. Disa. 1,141 • Total annual cost $2.9 billion

3. INTRODUCTIONAbdominal Trauma • Abdominal injuries present in 7-10% of admission • Present in ~ 20% of all trauma surgeries • ½ of preventable trauma death are related to inappropriate management of abdominal trauma • Extra abdominal injuries are clues to the presence of injuries within the abdomen • Abdominal injuries should be suspect in all trauma

4. 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?

5. 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

6. CLASSIFICATIONAbdominal Trauma • Penetrating • High velocity (85% penetrate peritoneum) • Low velocity (95% need surgery) • Stab(1/3 do not penetrate the peritoneum, of those 50% need Sx) • Blunt trauma • High energy transfer (car accident) • Low energy transfer (fall, fight)

8. Mandatory ExplorationAbdominal Trauma Anterior abdominal gunshot Stab Local exploration • Penetration of the fascia?? • DPL • Laparoscopy • Laparotomy Serial observation Surgeon’s expertise

9. Initial management for stab wounds

10. Blunt Injuries • Physical examination • Investigation • Case presentation • Specific organ injuries • Liver • Spleen • Small bowel

11. EpidemiologyInjuries From Motor Vehicle Passenger Restraints • Decrease mortality from MVC • Increase morbidity • Seat belt syndrome • Lap belt injury in children • C-spine injury • Air bag

12. Spleen 25% Liver 15% Hollow viscus 15% Ileum Sigmoid Kidney 12% Retroperitoneal 13% Mesentery 5% Compression Crushing Shearing Avulsion Blunt InjuryAbdominal Trauma

13. Physical ExaminationAbdominal Trauma Evaluation • BP and Pulse trend • Inspection • Seat belt mark • Skin lacerations • Previous surgery scar

14. Physical ExaminationAbdominal Trauma Evaluation • Auscultation • Palpation • Rebound tenderness • Guarding • Pregnancy • Pelvic instability

15. Physical ExaminationAbdominal Trauma Evaluation • Rectal examination • Prostate • Rectal tone • Vaginal examination • Gluteal fold • Penetrating injuries = abdominal injuries

16. Tube InsertionAbdominal Trauma Evaluation 4- Gastric tube • Relives distention • Decrease risk of unattended vomiting • But can induce it , risk of aspiration !!! Caution Facial fracture/basilar skull fracture

17. Tube InsertionAbdominal Trauma Evaluation • Urinary catheter • Monitor urinary output Caution • Inability to void retrograde • Pelvic fracture urethrogram • Blood at the meatus U/S • Scrotal Ecchymoses • High riding prostate

18. Special Diagnostic Studies Abdominal Trauma Evaluation • DPL • U/S • Ct abdomen & pelvis

19. X-RayAbdominal Trauma Evaluation • C-spine • Chest AP +/- paper clips for penetrating injury • High association of chest injuries and abdominal injuries • Free air? • Pelvis +/- paper clips for penetrating injury

20. Others X-RayAbdominal Trauma Evaluation • Urethrography 5. ? IVP for hematuria • IV contrast Keep good urinary output • Better CT scan 6. Spine fracture • Chance Fracture 20% small bowel injuries

21. Case PresentationJ.D. (3265709) -1 • 47 year old male Car felt on his Rt chest, LOC at scene? RUQ & Rt chest pain & deformity Rt shoulder • A good air entry • B Rt chest pain and bruising • C Pulse 92, Bp 120/90 HgB 140 EKG , few PVC, CK 1485, Triponin t < .05 • D GCS 15 • E Chest abrasions Rt side

22. Case PresentationJ.D. (3265709) -2 • Ct scan • Abdomen • Chest Xray

23. CT scan J.D. (3265709) -2

24. Case PresentationJ.D. (3265709) -2 • Ct scan • Grade III liver laceration • Intra abdominal free fluid • HgB decrease to 93 • Liver injury • 85 % observation • 10% -15% mortality • 15 % Laparotomy • 60 % mortality

25. Surgical management A significant liver 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

26. Surgical management (cont’d) Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use. Grindlinger 1998 TIP Patient selection Type of Trauma Age Associated injuries

27. Resuscitation • ATLS • Patient ‘s clinical condition • Persistent or recurrent hypotention • Hemorrhage • Prompt control of bleeding • Judicious volume restoration • Maintenance of pH and To TIP Duration of shock more critical than the amount of blood transfused

28. Blunt Liver Trauma Protocol1998

29. Outcome J Trauma;1998, 45,360

30. Outcome • Nonoperative • Less blood • mortality 15% Vs up to 63% • LOS shorter TIP decision to treat is base on the patient stability

31. Spleen Injuries • Diagnosis • Hemodynamic instability • LUQ pain • Left shoulder pain • 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

32. Small Intestine InjuriesEpidemiology • 15% of all laparotomy • High index of suspicion required • Serial examination • DPL diagnostic in 95 % • Enhance by enzyme • Increasing success with CT and laparoscopy • Delay in diagnosis increase M & M

34. Retroperitoneal air

35. Blunt Trauma in PregnancyAbdominal Evaluation • ½ Injuries due to MVA • Increase incidence of splenic injury and retroperitoneal bleed • Placenta abruption • 2-5% minor injuries • 20-50% in major injuries

36. Blunt Trauma in PregnancyTreatment • Multidiciplinary approach • Stabilization of mother status • Avoid venocaval compression • Used shielding during X-Ray • Aggressive Hypotention treatment • Establish gestational age • Ultrasound • C-section…Group decision

37. Blunt Trauma in PregnancyTreatment-2 • Abdominal evaluation • DPL supraumbelical approach • CT scan (5-10 cGy, Max is 10cGy) • Pelvic X-ray • Pelvic fracture: associated with fetal skull # • Unstable pelvic fracture = c-section (10%) • Monitoring in labor & delivery room • Rh- : RhiG within 72 Hours

38. EpidemiologyMultivariate Odd Ratio From 16,000 Patients • Gross hematuria 3.62 • Admission hypotension 3.53 • Lower ribs fracture 2.58 • Hemo/pneumothorax 2.49 • Abdominal wall hematoma 1.96 • Base deficit(HCO3 < 21) 1.77 • Pelvic fracture 1.5 (Brad Chushing)

39. 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”