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8/11/2019 Abdominal injury KNH GITHAIGA 2.ppt
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Abdominal Trauma
Githaiga J.W.
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Objectives
1.Evaluation of Abdominal Trauma
2.Mechanisms of Injury
3.Assessment of Unstable Patients
4.Assessment of Stable Patients
-Diagnostic tests
-Decision making
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Epidemiology
BLUNT AND PENETRATING ABDOMINAL TRAUMA AREMAJOR CAUSES OF MORBIDITY AND MORTALITY.
Combination injuries from bombs and explosive devices are onthe increase
In blunt abdominal trauma the spleen and liver are the mostcommonly injured organs and contribute to a mortality of 8.5%.
s attributable to RTA.
2/3RDS occur in males with a peak incidence in age 14 30yrs..
Penetrating injury has a higher mortality of up to 12%and
accounts for 1/3rdof all abdominal trauma. Gunshot and stab wounds account for 90% of penetrating
trauma.
Abdominal trauma more common in the urban set.
Males > females
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MECHANISMS OF INJURY
Shearing of organs and blood vessels due to
acceleration/deceleration forces.
Crush injury.
Rapture of hollow viscus due to rise in intraluminal pressure following compression.
Penetrating injury occurs directly from the
object causing the injury or from kineticenergy released by the object. This can
cause cavitation.
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Mechanism of Injury: Penetrating
Stab Low energy, lacerations
Gunshot
Kinetic energy transferCavitation, tumble Fragments
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Pattern of Injury in Blunt Abdominal Trauma
Spleen 40.6% Colorectal 3.5%
Liver 18.9% Diaphragm 3.1%
Retroperitoneum 9.3% Pancreas 1.6%
Small Bowel 7.2% Duodenum 1.4%
Kidneys 6.3% Stomach 1.3%
Bladder 5.7% Biliary Tract 1.1%
* Rosen: Emergency Medicine (1998)
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Management
Initial assessment and resuscitation.Establish that an abdominal injury exists
rather than emphasis on exact diagnosis.
Initial examination and resuscitation should
be simultaneous.
Principles of ABC should be applied ie
adequate airway,breathing and treating
hypovolumia. Rule out other injuries.
Insert wide bore IV cannula.
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Continous monitoring of BP,pulse rate ,
oxygen saturation.
Initial fluid resuscitation; rapid infusion
of 2 litres of crystalloid solution
followed by colloids if necessary.
Transient responders and non
responders for immediate laparotomy.
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Secondary survey
History of incident.
Physical examination of the exposed patient.
Examination of anterior and posterior abdomen.
Palapte for tenderness ,guarding and reboundtenderness.
Percussion and auscultation.
Rectal examination.
Perineal examination. Insert NG tube and urethral catheter.
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Assessment: History
AMPLE
Mechanism
MVC:
Speed Type of collision (frontal, lateral,
sideswipe, rear, rollover)
Vehicle intrusion into passengercompartment
Types of restraints Deployment of air bag
Patient's position in vehicle
A M P L E i l i f k
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A.M.P.L.E. - a simple mnemonic for key
information
A: allergies (e.g. penicillin or aspirin)
M: medication (e.g. a beta-blocker or warfarin)
P: previous medical history (e.g. previous
surgeryor anaesthetic mishap) L: last mealtime (i.e. drink versus major meal)
E: events surrounding the incident (e.g. fell 5metreswith immediate loss of consciousness)
Examine each body region meticulously
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A missed abdominalinjury can cause a
preventable death.
Abdominal Injury
Factors that Compromise the Exam
Alcohol and other drugs Injury to brain, spinal cord Injury to ribs, spine, pelvis
Caution
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Decision Making
Airway
Breathing
Circulation
HemodynamicallyStable
Hemodynamically
Unstable
Transient
Responder
S H O C K
How are you going to assess?
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Decision Making
Stable patient
CT Scan
Operative
Solid organ injury, hypotensive
Hollow viscus organ injury
Intraperitoneal bladder injury
Diaphragmatic injury Non-operative management
Observation
Interventional Radiology
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Options for Management
Laparotomy Hemodynamic Stability?
Diffuse Abdominal Tenderness
Yes No
Indications for Laparotomy Penetrating Trauma
Hemodynamically abnormal Peritonitis Evisceration Positive DPL, FAST, or CT Violation of peritoneum
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Options for Management
Hemodynamically stable penetrating injury
Serial Observation
Wound Exploration
DPL
CT scan +/- Contrast
Laparoscopy
Laparotomy
Ultrasound/echocardiac box
Pericardial windowcardiac box
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Investigations
In haemodynamically stable patients.
Full blood count and haematocrit.
Urea and electrolytes. FAST; Focused Abdominal Sonography
for Trauma- detects free fluid in the
peritoneal cavity. Non invasive andrapid. 88% sensitive,99% specific and
97% accurate.
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Focused Abdominal Sonography for Trauma
(FAST)
Demonstrate presence of free intraperitonealfluid
Evaluate solid organ hematomas
AdvantagesNo risk from contrast media or radiationRapid results, portability, non-invasive, ability to repeat
exams.
DisadvantagesCannot assess hollow visceral perforationOperator dependentRetroperitoneal structures are not visualized
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FAST Four View Technique:
Morrisons pouch (hepatorenal)
Douglas pouch (retropelvic)
Left upper quadrant (splenic view)
Epigastric (View pericardium)
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Diagnostic peritoneal lavage
98% sensitive in detecting intra
abdominal bleeding.
Does not detect diaphragmatic injuries.
Poor at detecting retroperitoneal bleed.
Invasive procedure.
Contraindicated in patients withprevoius surgery,pregnancy.
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Negative criteria; RBC count < 50,000/ul
( in penetrating trauma
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CT Scan
Replacing DPL.
98% sensitive in detecting intraperitoneal
bleeding.
Contrast enhanced CT Scan gives usefulanatomical and fuctional information on
organs.
Can identify organ injuries and be used todetermine which injuries can be managed
conservatively in stable patients.
Useful in grading solid organ injuries(liver
and spleen)..
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Laparoscopy
Increasingly used in assessing trauma.
Useful in determining peritoneal
penetration and identifying
diaphragmatic injuries.
Also can be used for treating certain
injuries.
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Mangement
Principles of management are;
Stop haemorrhage.
Debride devitalised tissues. Repair injured bowel by suturing or
resection.
Eliminate foreignbodies/contamination and intestinal
contents.
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Preoperative preparation
Immediate surgery once significant
injury is confirmed or in
haemodynamically unstable patients.
Broad spectrum antibiotics to cover
both aerobic and anerobic organisms.
Investigations and clinical findings
should guide management in stable
blunt injury patients.
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Management cont`d
Blunt abdominal trauma.
Initial assessment and resuscitation;
Haemodynamically stable or unstable.
Haemodynamically stable and no
peritonitis, negative DPL, negative
FAST, Negative CTScan observation
and serial examinations.
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Haemodynamically unstable;
Laparotomy.
Positive DPL Laparotomy
Intra-peritoneal fIuid seen on FAST
Laparotomy.
CT Scan findings of solid viscus ( liver
/spleen) injury - grade of injury
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Indications for Laparotomy Blunt Trauma
Hemodynamically abnormal with suspectedabdominal injury (DPL / FAST)
Free air
Diaphragmatic rupture
Peritonitis
Positive CT
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aAbdominal traumabaaado
Gun shotGunshotStab wound
Bluntabdominal
trauma
Mandatorylaparotomy
Evisceration,positive DPL,
Haemodynamic
instabilty,peritonitis
Stable ;
FAST,CTScan,DPL
Unstable
haemodynamically
LAPAROTOMY
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THANK YOU
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Spleen
Spleen is the commonest injured organ in blunt
abdominal trauma.
Fractures of the left lower ribs are associated with
spleen lacerations in 20 % of cases.
Most splenic injuries can be managed conservatively
after grading with CT Scan.
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Grade 1 SPLENIC INJURY
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Grade 3 injury
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Splenic injury
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Bowel
The small intestines takes up a large part of the
abdomen and is likely to be damaged in penetrating
injury.
The bowel may be perforated.Gas within the
abdominal cavity seen on plain abdominal X-Ray orCT is diagnostic.
Bowel injury may be associated with complications
such as infection, abscess, bowel obstruction, and
the formation of a fistula. Bowel perforation requires surgery.
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Perforated viscus
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Stab wound with evisceration
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Management
Splenic and liver injuries grade 1,2 and
3 may be treated conservatively.
Grade IV and V Laparotomy.
Evisceration -laparotomy
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Thank you