Surgery - Abdominal Trauma

Primary Survey and Initial Resuscitation Abdominal Trauma Renato R. Montenegro, MD, FPSGS

Assistant Professor UST Faculty of Medicine & Surgery

Multiple Choice: You are driving along Roxas Blvd when you chanced on a vehicular accident. You would ... A. Drive away as quickly as you can B. Slow down; assess situation; decide there are enough on-lookers providing help; leave C. Stop some distance away; call nearest hospital / police station to report accident; leave D. Make a dramatic entrance: step on breaks instantly so everybody sees / hears / smells your burning tires; push everyone aside, announce you are a UST Medical senior and that henceforth you are in charged !

Objectives • • • •

For the student to learn that there is a systematic way of managing trauma …to realize that there is no single protocol applicable to all situations and conditions …to be familiar with a protocol in the management of trauma …that as medical students (or paramedics or laymen), knowledge of the basics in trauma can spell a significant difference

Trauma • leading cause of morbidity and mortality under age 45 • 3rd highest cause of death in all ages • ages 15-24: accidents claim more lives than all other causes combined • 150,000 Americans die each year > # of deaths in Vietnam; (VA=50%) • Trauma death rate: 50 / 100,000 • Mortality rates are poor indicators of the problem

TRAUMA: with a clearly identified beginning which if not rapidly and properly managed may lead to death of the victim TRAUMATIC EVENT

GOLDEN

PRODUCTIVE MEMBER OF SOCIETY

HOUR 0

RECOVERY MORBIDITY MORTALITY

TIME

Historical Notes 1945 1965 1967

Atomic bomb dropped at Hiroshima Diagnostic Peritoneal Lavage (Root, et al) National Academy of Science milestone report – “Trauma: The neglected disease of Modern Society” 1970 Triage, Resuscitation, Fluids, ARDS 1971 Ultrasound 1972 CT Scan 1998 Focused Abd. Sonography for Trauma (FAST) Diagnostic Laparoscopy for Trauma 2001 911

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150,000 trauma deaths per year 50% from vehicular accidents Blunt abdominal trauma accounts for majority of deaths vehicular accidents account for majority of blunt hepatic trauma

Almost 2,000 people are killed and another 50,000 injured every year in motorcycle accidents in the United States.

TRAUMA : The Neglected Disease of Modern Society

The American Academy of Medicine

Trauma TRAUMA: Emergency Management Basic Assumptions: 1. Patient may have more than 1 injury 2. The obvious injury is not necessarily the most important Identify Categories of Injury Initial Resuscitation - The ABC’s

Categories of Injury – Identifying Priorities 1. Exigent - most life-threatening - instantaneous intervention e.g. laryngeal fracture, tension pneumothorax 2. Emergency - immediate intervention within first hour e.g. ongoing hemorrhage, intracranial injuries 3. Urgent - intervention within first few hours e.g.- open fractures, ischemic extremity, hollow viscus injury 4. Deferrable - may or may not be immediately apparent but will require tx. - e.g. facial fractures, urethral injury

Treatment of Trauma Patients     

Primary Survey (ABC) Resuscitation Secondary Survey Diagnostic Evaluation Definitive Care

The ABCs of Resuscitation A - Airway B - Breathing C - Circulation D - Disability / Neurologic Assessment E - Exposure for Complete Examination

Airway Management    

Assess mental status / verbal output Inspect oropharyngeal cavity Methods for establishing airway Problems: altered MS, foreign body, neck injuries, maxillofacial trauma, edema to air passages

Breathing 

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Oxygenation and ventilation Problems: tension / open pneumothorax, flail chest, pulmonary contusion Diagnosis: clinical, chest x-ray

Thoracostomy • Needle thoracentesis • Closed Tube thoracostomy • Water-sealed drainage bottle

Circulation  

Assumption: hypotension is caused by bleeding Assess pulses: Radial = 80 mmHg Femoral = 70 mmHg Carotid = 60 mmHG

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Vital Signs: BP, PR, RR Methods to control hemorrhage Hypovolemic shock vs Cardiogenic shock

Cardiac Tamponade  

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Index of suspicion: unexplained hypotension Diagnosis: increased venous pressure, decreased pulse pressure, decreased heart sounds Dx procedures: Pericardiocentesis, Chest x-ray, FAST, 2-D ECHO Pitfall in dx: waiting for a complete diagnostic triad Treatment : Pericardiocentesis, Pericardiostomy

FAST for Cardiac Tamponade

Pericardiocentesis •Index of suspicion: unexplained hypotension •50 % false negative •A temporizing therapeutic procedure which may be lifesaving

Resuscitation      

Establish airway / oxygenate patient Insert large-bore IV lines Draw blood for typing and cross-matching; consider universal donor transfusion Volume resuscitation with crystalloid solution Definitive treatment for non-responders Diagnostic work-up for responders

Abdominal Trauma: Mechanism and Pattern of Injury BLUNT 

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Energy transfer to a wide area Vehicular accident, steering wheel injury, fall, More delays in dx Higher mortality rates

PENETRATING 

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Injury localized to path of SW or GSW Easy to diagnose Better outcome

Range of P.E. Findings in Abdominal Trauma I. BLUNT ABDOMINAL INJURY

Normal P.E.

Equivocal P.E.

Unstable patients /obvious indications for surgery

II. PENETRATING ABDOMINAL INJURY

Equivocal P.E.

Unstable patients /obvious indications for surgery

Indications for immediate surgery

STAB WOUND

Local wound exploration

-Unstable VS -evisceration -Peritomitis

Positive LWE

- signs of bleed

Diagnostic peritoneal lavage (DPL)

To OR for surgery

+ DPL

Negative LWE

Observe/ discharge pt

- DPL

Indications for immediate surgery

STAB WOUND

-Unstable VS -evisceration -Peritomitis - signs of bleed

To OR for surgery

Negative LWE

STAB WOUND

Local Wound Exploration  

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For stable SW patients To determine penetration beyond the peritoneum Positive LWE: peritoneum is violated (+) LWE: reasonable likelihood of intraperitoneal injury

Local wound exploration

Negative LWE

Observe/ discharge pt

STAB WOUND

Local wound exploration

Positive LWE

Diagnostic peritoneal lavage (DPL)

Negative LWE

Indications for immediate surgery

STAB WOUND

Local wound exploration

-Unstable VS -evisceration -Peritomitis

Positive LWE

- signs of bleed

Diagnostic peritoneal lavage (DPL)

To OR for surgery

+ DPL

Negative LWE

Observe/ discharge pt

- DPL

Diagnostic Peritoneal Lavage 

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(Root et al, 1965) The first serious departure from mandatory laparotomy for suspected blunt abdominal injury Fast, very sensitive (97-98%) Specialized training not required May be done in a variety of locations Results are quantitative, objective, operator independent

Diagnostic Peritoneal Lavage

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Abdominal paracentesis Peritoneal catheter Infuse lavage fluid (NSS/LRS) Drain after 20-30 minutes Analysis of effluent fluid Positive results are indications for explore laparotomy

Positive (DPL) •Aspiration of 10 ml free blood •Effluent drains in NGT, Chest tube, Foley catheter •RBC > 100,000/cu ml •Bile, bacteria, vegetable fibers, fecal material detected •Amylase, alkaline phosphatase detected

Diagnostic Peritoneal Lavage INDICATIONS:  closed head injury / altered consciousness / SC injuries  equivocal abdominal findings

NOT RECOMMENDED:  previous abdomial surgery  presence if dilated bowels  Pregnancy  SW , back  GSW

Blunt Abdominal Trauma 

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Trauma remains the leading cause of death in 1 – 44 year old age group Most deaths caused by blunt injury VA accounts for most blunt hepatic injury Diagnosis is a challenge and continues to evolve Non-therapeutic laparotomy weighed against delayed / missed diagnosis Range of PE findings Normal P.E.

Equivocal P.E.

Unstable patients /obvious indications for surgery

Diagnosis of B.A.T. 1. 2. 3. 4. 5. 6.

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Physical Exam Lab. Studies (serial Hb/Hct) Diagnostic Peritoneal Lavage Ultrasound CT Scan FAST (Focused Abdominal Sonography for Trauma) Diagnostic Laparoscopy

Diagnosis of B.A.T. Physical Exam  Most useful in primary survey to identify lifethreatening injuries and to set priorities  Useful in secondary survey to identify patients with E/N physical exam who may not require any work-up  In equivocal cases: wide variabilty in sensitivity  50-60 % sensitive

Plain radiographs  Abdomen x-ray: unreliable due to uniform fluid density of abdomen  Chest x-ray mandatory Lab Studies  Serial Hb/Hct – useful monitor of hemorrhage over a period of time rapid hemorrhage - false negative crystalloid hemodilution - false positive 

Arterial Base Deficit - index of metabolic acidosis in setting of hemorrhage

Chest x-ray  

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Mandatory procedure May show pneumoperitoneum To document problems in the lungs and pleura

Traumatic Diaphragmatic Hernia

Diagnosis of Blunt Abdominal Trauma   

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Physical exam lacks sensitivity Not all patients with BAT require studies All patients with abdominal SW require some type of objective evaluation Utilize studies to arrive at dx early at the NONsame time minimize non-tx laparotomy THERAPEUTIC

MISSED / DELAYED DIAGNOSIS

LAPAROTOMY

DPL: disadvantages Invasive (<1% complication rate)  Not very specific  May miss retroperitoneal, diaphragm injuries  Highly sensitive increases incidence of non-therapeutic laparotomy 

ADJUST CELL COUNT THRESHOLD

DPL  

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Recommended cell count threshold = 100,000 cells/cu mm Institutions / practitioners must evaluate their own tolerance for and consequences of delayed diagnosis vs. non therapeutic laparotomy Indications have diminished with use of CT and FAST Still useful in intra-op evaluation of trauma patient undergoing emergency surgery at a site remote from the abdomen (eg. Craniotomy)

Abdominal CT Scan     

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Very specific (95-100%) Good sensitivity (85-99%) Can evaluate the retroperitoneum Allows staging of blunt organ injuries Most major injuries are operator (reader) independent Dx modality of choice for hemodynamically stable patients with suspected blunt abdominal injury

CT scan: BAT 

Computed tomography scan identifying an intraparenchymal liver hematoma with overlying rib fracture

CT scan: BAT 

Computed tomography demonstrating a focal splenic laceration involving the posterior aspect of the spleen

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Small amounts of blood associated with solid organ injury is not an independent indication for exploration

Abdomen CT Scan: disadvantages 

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Requires time and patient transport Has some degree of operator dependence May miss blunt intestinal injuries

Focused Abdominal Sonography for Trauma (FAST) 

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Diagnostic procedure of choice in the unstable patient Fast, simple, portable, readily available Short learning curve Positive finding: fluid (blood) in peritoneal cavity

Blunt Abdominal Injury 

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22 y/o, male fell off his motorcycle (?20 mph) Ambulatory, in pain, BP=90/min, PR=120 Hematoma in mid abdomen Diagnostic procedure ?

Seat Belt Sign

Thank You.