Abt for Corrections 22CORRECTIONS-10

8/13/2019 Abt for Corrections 22CORRECTIONS-10

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CERTIFICATE BY GUIDE

This is to certify that this Dissertation on

"ABDOMINAL TRAUMA- A CLINICAL PROFILE"has been carried out by Dr.

KUMBHA NAGA SUNEETHA, M.B.,B.S., who is a post graduate student working under my

direction, guidance and supervision, in partial fulfillment of the rules and regulations laid down

by N.T.R University of Health ciences, !i"ayawada, to appear for #. $%eneral urgery&

Degree '(amination to be held in )*R+-/01.

Date2

*lace2 !+)3H)*)TN)#.

Dr. G.ARJUNA, M.S.

*R45'4R 45 %'N'R) UR%'R6

D'*)RT#'NT 45 %'N'R)UR%'R6

)NDHR) #'D+7) 74'%'

3+N% %'4R%' H4*+T)

!+)3H)*)TN)#


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CERTIFICATE BY HOD

This is to certify that the Dissertation on

ABDOMINAL TRAUMA- A CLINICAL PROFILE" is the bonafide work carried

4ut in )ndhra #edical 7ollege 8 3ing %eorge Hospital. !isakhapatnam by

Dr.KUMBHA NAGA SUNEETHA, M.B.,B.S., who is a *ost %raduate student

working under my direction, guidance and supervision, in the partial

fulfillment of rules and regulations laid down by N.T.R. University of Health

ciences, !i"ayawada, to appear for #.. (%eneral urgery& degree e(amination to

be held in )pril /01

P!"# $!isakhapatnam

D!%# Dr.N.SUBBARAO ,M.S.

Pr&'#&r ) HOD &' %*# +#!r%#%

D#!r%#% &' /##r! 0r/#ry

K1/ G#&r/# *&1%!

21!3*!!%!


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ABDOMINAL TRAUMA- A CLINICAL PROFILE

) Dissertation ubmitted to the

Dr. N.T.R. UN+!'R+T6 45 H')TH 7+'N7', !+9)6):)D)

In partial fulfillment of the Rules and Regulations for

#.. ;%eneral urgery< D'%R'' '=)#+N)T+4N

To be held in

)*R+- /01.

Dr. KUMBHA NAGA SUNEETHA, M.B.B.S.,

Under the Direction and Guidance of

Dr.G.ARJUNA M.S.

*R45'4R 45 %'N'R) UR%'R6

D'*)RT#'NT 45 %'N'R) UR%'R6

)NDHR) #'D+7) 74'%'

3+N% %'4R%' H4*+T)

!+)3H)*)TN)# $).*&


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ACKNO4LEDGEMENTS

+ e(press my sincere thanks and deep sense of gratitude

to Dr.N.SUBBARAO M.S. *rofessor of %eneral urgery, )ndhra #edical

7ollege,!isakhapatnam, :ho has taken keen interest and rendered his most

valuable guidance and supervision in each and every step of my effort in

preparing this dissertation.

+ sincerely acknowledge my heartful thanks to my respected professors

Dr.N.Dwarakanadh#..#ch., Dr..!.3umar.#.., Dr.7h.waminaidu.#..,

Dr.)r"una.#.., Dr.T.Narayanarao.#.., Dr.ivakumar.#.., Department of

general surgery, )ndhramedical college, !isakhapatnam for their valuable

guidance. + am thankful for their encouragement and advice.

+t is my great privilege to honestly thank my associate professors

Dr.Ra"agopal.#.., Dr.!.#anmadharao.#.., Dr.R.>havanirao.#.., and

assistant professors Dr.*.).Ramani.#.., Dr.3.9anardhanrao.D.N.>.,

Dr.>.7haitanyababu.#.., Dr..Ratnakishore.#.., for their valuable

guidance, encouragement and advice.

+ also thank *rincipal )ndhra #edical 7ollege, !isakhapatnam,

faculty of Department of Radiology for permitting me to carry out this work.

+ am thankful to all my colleagues for their co-operation and help throughout

the present study.

ast, but not the least + am grateful to the patients who have submitted

themselves for this study and for their remarkable co- operation.

(Dr.RAJESH MUPPANA5


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LIST OF ABBRE2IATIONS

0. %7 %lgasgow 7oma cale

. T+ Therapeutic +ntervention core ystem

?. )+ )bbreviated +n"ury cale

1. + +n"ury everity core@. )*)7H' )cute *hysiological and 7hronic Health

A. D* Diagnostic *eritoneal avage

B. R>7 Red >lood 7ell

C. :>7 :hite >lood 7ell

. +U8 +nternational Units *er iter

0/. +!U +ntravenous Urography

00. 7T 7omputeriEed Tomography

0. 5)T 5ocused )ssessment onography in Trauma

0?. #R+ #agnetic Resonance +maging

01. )>% )rterial >lood %as

0@. 4T 4peration Theatre0A. %+ %astro-intestinal

0B. 'R7* 'ndoscopic Retrograde 7holangio *ancreaticography

0C. 7>D 7ommon >ile Duct

0. +!* +ntravenous *yelogram

/. +!7 +nferior !enecava

0. %' %astro-esophageal

. U% Ultrasonography


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74NT'NT

*age No.

*)RT - +

0 +NTR4DU7T+4N

R'!+': 45 +T'R)TUR'

*)RT - ++

0. )+# )ND 4>9'7T+!'

. #)T'R+) )ND #'TH4D

?. 7)' H''T

1. 4>'R!)T+4N )ND R'UT

@. D+7U+4N

A. 74N7U+4N

B. >+>+4%R)*H6

C.#)T'R 7H)RT


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INTRODUCTION

+n"ury is the leading cause of death and disability in the first four decades of life and is

the third most common cause of death overall.

+n +ndia communicable diseases continue to take the ma"or share even now, still in"ury

is responsible for BF of all deaths. )bout 0 in 1/,/// individuals die in +ndia every year,

whereas appro(imately double the number is disabled and this number is increasing.

>y convention, in"ury is classified into several categories - *enetrating, >lunt or

Nonpenetrating, >last overpressure, Thermal, 7hemical and others including crush and

barotrauma. +n blunt in"uries, the damage may be caused by acceleration, deceleration, rotational

or shearing forces.

Trunkey has pointed out that deaths due to trauma fall broadly into three groups, giving a

distinct trimodal pattern.

0. +mmediate deaths $@/F&

. 'arly deaths $?/F&

?. ate deaths $/F&

+t is among those cases represented by second and third peaks that potentially preventable

deaths occur. 4f one fourth to one third of the deaths from trauma could be prevented by more

effective initial care. The primary aids like airway management, restoration of circulation, care

of cervical spine, cardiopulmonary resuscitation is carried out in the initial stages. Roughly 0/F

have life threatening in"uries and speed in diagnosis and therapy is crucial to their survival.


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coring systems have been developed to facilitate triage, research and Guality assurance.

#ore recently their ability to predict morbidity and mortality particularly septic complications

have been studied.

)bdominal trauma is one of those sub"ects where the skills of the surgeon is "udged, both

in correct diagnosis of the associated visceral in"uries and in treating them, promptly and

skillfully, since the morbidity and mortality is very high if not treated adeGuately.

:ith the increase in the number of motor vehicle accidents, there is rising incidence of

abdominal trauma. The abdomen is the third most commonly in"ured body region, with in"uries

reGuiring operation in about /F of civilian trauma victims. )bdominal in"uries can be

particularly challenging because it is often difficult to assess the intra abdominal pathology in the

multiple in"ured victim. There is also masking of abdominal in"uries by associated conditions

like head in"uries, fractures, alcoholism, drug abuse, shock etc.

+nitial clinical assessment of the abdomen in blunt trauma is accurate in only B/-C/F of

cases. aparotomy should be done when in doubt in a patient with multiple in"uries where all

clinical and other investigations have failed to e(clude the abdomen as a source of shock

syndrome he displays. )s more and more improvements in the diagnostic modalities for

abdominal trauma are forthcoming a therapeutic approach towards conservation with decreased

operative intervention has been increasing especially for solid organ in"uries.

The ob"ect behind my study is to present a comprehensive picture of the recent concepts

in assessment and management of abdominal in"uries in our setup and to highlight upon the

diagnostic difficulty it poses and the distressing high mortality it carries. The dissertation has

review of literature on the sub"ect and report on the nature of in"ury, type of viscera in"ured,


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treatment offered for abdominal in"ury patients, admitted to 3ing %eorge Hospital,

!isakhapatnam during the period of #ay /00 to 4ctober /0?.


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RE2IE4 OF LITERATURE

HISTORICAL RE2IE4

)ristotle was the first person to describe about visceral in"uries due to blunt trauma. ater

on Hippocrates and %alen have given description about this condition. 4ne of the most

interesting early practitioners of trauma care was %alen $0?/-// ).D&. %alens book became

the primary source for treatment of wounds throughout the middle ages.

+ndias system of trauma care has rivaled the Romans. During the reign of )shoka $A-

? >.7&, the )rthashastra was written. This book documented that army had an ambulance

service with well eGuipped surgeons. )t appro(imately the same time a very famous surgeon

ushrutha lived and treated patients in >enaras.

)mbroise *are $0@0/-0@/ ).D& ma"or contribution in treating in"uries include his

treatment of gunshot wounds, use of ligature instead of cautery and use of nutrition during post

in"ury period

Traverse $0CB& has reported fracture of body of pancreas caused by blunt trauma. 4wen in

0C1C gave a graphic description of a case of closed abdominal in"ury and fatal hypovolemic

shock due to liver rupture following a fall.

9ance $0C@A& described a fatal isolated pancreatic in"ury due to a kick. !on

Reclinghausen $0CA0& described renal artery thrombosis occurring as a result of blunt in"ury. +n

0CB/ >urn was the first one to resect the liver successfully and >urkhart in 0CCA controlled

acute traumatic liver haemorrhage by suturing.1

ongrat $0CB@& was the first person to study the pathogenesis of rupture of bowel. +n

0CC, #arion imms began to emphasiEe the need for laparotomy in the case of abdominal

trauma. +n 0CCA, Riolti successfully repaired a torn left dome of diaphragm caused by fall from

a tree. 3een $0C& e(cised left lobe of liver using cautery.


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%rant #ussay $0?& wrote that -in closed abdominal in"uries, early diagnosis is almost

impossible and must be guided by general consideration of clinical picture than presence or

absence of any particular sign.

)inheim in 0?1 described abdominal paracentesis as a diagnostic procedure. Root in

0A@ popularised the techniGue of peritoneal lavage, though it was first suggested by olomon

in 0/A. during the 5irst :orld :ar, the treatment of abdominal in"uries was mainly

conservative with a mortality around BBF. Hence, in :orld :ar ++, e(ploration was done for

all, thus bringing down the mortality to @F.

ANATOMY OF ABDOMEN

M0"# &' Ab+

#uscles of abdomen can be divided into anterolateral and posterior groups.

)NT'R4)T'R) #U7' 45 )>D4#'N

7onsists of four large flat muscular sheets.

0. '(ternal obliGue.

. +nternal obliGue.

?. Transversus abdominis.

1. Rectus abdominis.

*4T'R+4R #U7' 45 )>D4#'N2

There are four muscles forming posterior wall of abdomen.

0. *soas ma"or.

. *soas mr.

?. +liacus.

1. Iuadratus lumborum.

FASCIA

5asciae in relation to abdominal wall can be divided into2

0. Those in relation to anterior abdominal wall.


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. Those in relation to posterior abdominal wall.

5)7+) +N R')T+4N T4 )NT'R+4R )>D4#+N) :)2

0. uperficial fascia which is divided into superficial fatty layer 7amper and deep membranous

layer carpa

. Rectus sheath.

?. Transversalis fascia.

5)7+) +N R')T+4N T4 *4T'R+4R )>D4#+N) :)2 TH4R)74U#>)R

5)7+).

+t has three layers. *osterior layer,middle layer and anterior layer.

NEURO2ASCULAR PLANE

The abdominal wall is supplied by all the lower si( thoracic nerves via intercostal nerves

and the first lumbar nerve via iliohypogastric and ilio-inguinal nerves.

The nerves and vessels run in the plane between transverse abdominis and internal obliGue

musles.

LYMPHATIC DRAINAGE

)bove the umbilicus drain into *ectoral group of a(illary nodes. >elow the umbilicus go to the

uperficial inguinal lymph nodes.

PERITONEUM

*eritoneum is a fibrous membrane lined by mesothelium. That part of peritoenoum which lines

linea alba, the anterior and posterior abdominal walls is the parietal peritoneum. *arietal

peritoneum is supplied by nerves supplying abdominal muscles.

That part of peritoneum investing the viscera is known as visceral peritoneum and is

devoid of nerve supply and hence pain insensitive.

*'R+T4N') 7)!+T6


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The potential space between these two layers containing a few ml, of tissue fluid is known as

peritoneal cavity. This poritoneal cavity is divided into greater sac and lesser sac communicating

through foramen of :inslow or epiploic foramen lying between the first part of duodenum and

the undersurface of liver. +t is limited anteriorly free edge of lesser omentum and posteriorly

inferior venecava.

%R')T'R )7

+t is divided into supracolic compartment and infracolic compartment by the transverse

mesocolon.

upracolic compartment is further divided into right half and left half by falciform

ligament.

upracolic compartment is continuous with right paracolic gutter whereas the left

paracolic gutter is separated by phrenico-colic ligament. +nfracolic compartment is divided into

right and left halves by attachment of mesentry e(tending from duodenal-"e"unal "unction to right

iliac fossa.

''R )7

+t is also called as omental bursa and lies behind the stomach.

OMENTUM

These are peritoneal folds. There are omenta2 %reater and lesser omentum,

%R')T'R 4#'NTU#

This is the largest peritoneal fold. +t consists of a double sheet folded on itself so that it is made

up of four layers. The two layers which descend from the stomach and 0 stpart of duodenum pass

downwards infront of small intestines for a variable distance then turn upon themselves and

ascend as far with upper layer of transverse mesocolon.

That part of greater omentum e(tending from greater curvature to diaphragm is called

gastrophrenic ligament. The part e(tending from greater curvature to spleen is known as


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gastrosplenic ligament. That part between spleen and left kidney is le-renal ligament and the part

between greater curvature and transverse colon is gastrocolic ligament.

''R 4#'NTU#2

+t e(tends form lesser curvature of stomach and commencement of duodenum to the

undersurface of liver. Hepatic attachment is 9 shaped, horiEontal limb corresponding to the

margin of porta hepatis.

2ISCERA

!iscera of supra colic compartment are liver, spleen, and stomach, and that of infracolic

compartment - small intestine and large intestine.

LI2ER

iver is the largest organ in the body situated in right hypochondrium and epigastric region .

+t has 1 lobes and 1 surfaces2

54UR 4>'

0.Right lobe, .eft lobe,?.7audate lobe and 1.Iuadrate lobe.

54UR UR5)7'

0.uperior surface,.*osterior surface ,?.Right surface and 1.+nterior

surface

'%#'NT) )N)T4#6

The line drawn from bed of gall bladder to inferior vena cava divides the iver into right

lobe and left lobe. Right lobe is divided into anterior and posterior segments. eft lobe is divided

into medial and lateral segments. )ll these segments are divided into superior and inferior

segments.

*'R+T4N') 74NN'7T+4N 45 +!'R


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0. 5alciform ligament,.Right triangular ligament,?.eft triangular ligament,1.7oronary

ligament and @.esser omentum.

SPLEEN

*rincipally situated in the left hypochondrium. +ts long a(is lies in line of 0/th

rib.

+t has diaphragmatic and visceral surfaces. Upper and lower border and anterior and posterior

e(tremities.

The diaphragmatic surface is conve(, smooth and faces upwards and to left. The visceral

surface is directed towards the abdominal cavity and has gastric, renal, pancreatic and colic

impressions.

%astrosplenic ligament e(tends form greater curvature of stomach to spleen. e renal

ligament-is the peritoneal fold $ part of greater omentum& e(tending from spleen to left kidney.

STOMACH

tomach has openings - cardia and pylorus , curvatures Jgreater curvature and lesser

curvature , surfaces J antero superior and postero inferior and ? parts J fundus ,body and

antrum.

)NT'R4U*'R+4R UR5)7'

5undic part is in relation to the diaphragm. Upper and left part of this surface is in contact

with the gastric surface of spleen. The right half is in relation to the inferior surface of liver and

anterior abdominal wall.

*4T'R4+N5'R+4R UR5)7'

This is related to diaphragm, left superarenal gland, upper part of left kidney, splenic

artery and anterior surface of pancreas, left colic fle(ure and upper layer of transverse

mesocolon.

These structures from the stomach bed but the stomach is separable from them and can

slide over them due to the intervening omental bursa.


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STRUCTURES OF INFRACOLIC COMPARTMENT

6. SMALL INTESTINE 2

'(tends from pylorus to ileocaecal "unction. +t is A-B meters in length. 4f this 8@ th is

"e"unum and ?8@this ileum. +t covered by peritoneum e(cept over duodenum and is attached to

posterior abdominal wall by mesentry.

DUODENUM$

@cm long and is the most fi(ed part of small intestine.

C&1% &' 7 !r%$

0. 0stuperior, . ndDescending, ?.?rdHoriEontal and 1.1th)scending.

R')T+4N

0- S0#r1&r !r%$ related anteriorly to Guadrate lobe and posteriorly to gastro-duodenal )rtery,

bile duct and portal vein.

- S#"&+ !r%$ related anteriorly to duodenal impression on right lobe of liver, tranverse colon

and transverse mesocolon. *osteriorly to right kidney. )mpulla of vater open into the middle of

this part on postero medial aspect.

?. T*1r+ !r%$ related anteriorly to superior mesenteric artery and the root of mesentry.

*osteriorly to right ureter, +nferior vena cava and aorta $origin of inferior mesenteric artery&.

1. F&0r%* !r%$ related anteriorly to the transverse colon and transverse mesocolon, posteriorly

to the left kidney and ureter.

JEJUNUM AND ILEUM

0. Diameter of "e"unum is $1cm& more than ileum $?.@cm&.

. !ascular arcades are less in "e"unum one as compared to ileum two or more.

?. 9e"unum is double layered $because the mucosa is folded to produce valves&, while ileum is

single layered.

1. #esenteric fat encroaches on to "e"unal wall but not in case of ileum.

COLON

0. 7olon is 0.@ meters long has a greater diameter.


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+t is distinguished by taenia coli formed by longitudinal muscle fibres, the presence of

)ppendices epipoicae and presence of haustrations.

RECTUM

+t is 0 -0C cm. ong, e(tending from ?rdpiece of sacrum to "ust below the tip of coccy(.

The longitudinal muscle spreads to encircle whole circumference. +t has no appendices

epiploicae and haustrations.

5)7+)

0. 5ascia of :aldeyer2 avascular dense connective tissue between sacrum and rectum.

. ateral ligament of rectum, e(tending from lateral wall of pelvis to rectum containing middle

rectal vessels.

?. 5ascia of Denonvillier is the loose areolar tissue between rectum posteriorly and seminal

vesicles and prostrate anteriorly.

STRUCTURES OF RETROPERITONEUM$

6. PANCREAS

*ancreas is situated transversely behind the stomach from the duodenum to the spleen. +t has

head, neck, body and tail.

0. H')D$ lies in the curve of duodenum and is related to inferior vena cava.

. N'73$ related anteriorly to gastroduodenal artery and its branches, *osteriorly.

?. >4D6$ related anteriorly to omental bursa and posteriorly to aorta and origin of superior

mesenteric artery, left supra renal artery and left kidney.

1. T)+$ contained in the layers of lerenal ligament and intimately related to hilum of spleen.

KIDNEY


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'(tends from upper border of 0 ththoracic vertebra to the lower border of ?rd lumbar vertebra.

Right kidney is at a lower level than the left kidney.

R+%HT 3+DN'6 + R')T'D )NT'R+4R6

Nearer superior pole to suprarenal gland and a large area below this to hepatic area. #edial

border is in contact with descending part of duodenum. +nferiorly kidney is related to right colic

fle(ure.

*osteriorly it is related above to diaphragm and below $from medial to lateral& Guadratus

lumborum andKtransverses tendon.'5T 3+DN'6 + R')T'D )NT'R+4R6

4n superior aspect to suprarenal gland, lateral half to spleen, medial area to stomach, middle area

to pancreas and below the pancreatic area laterally to colon and medially to coils of "e"unum.

%R')T !'' 45 )>D4#'N

0,)>D4#+N) )4RT)

>ranches 0. !entral -7eliac trunk

-uperior mesenteric artery

-+nferior mesenteric artery

. ateral -inferior phrenic artery

-middle suprarenal artery

-renal artery

-artery to testis8 ovary

?. Dorsal -lumbar artery

-middle sacral artery


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1.Terminal Jcommon iliac artery

. +N5'R+4R !'N)7)!)

5ormed by union of two common iliac veins, on right side of the body of @ vertebra,

ascends in front of vertebral column on the right side of aorta.

GENERAL FEATURES OF ABDOMINAL INJURIES

T*# 8!r1&0 C!0# !r# ! '&&9$

Road traffic accidents

+ndustrial accidents

5all from height

)ssault

Run over by vehicles

ports in"ury

M#"*!1 &' 1:0ry$

>lunt in"uries are thought to result from a combination of 0& crushing & deforming ?&

stretching and 1& shearing forces. The magnitude of these forces is directly related to the mass

of the ob"ects involved, the rate of the acceleration or deceleration and the relative direction on

impact. +n"ury results when the sum of these forces e(ceeds the cohesive strength of the tissue

and organs involved.

*enetrating abdominal trauma whereby the abdominal cavity communicates with the

e(terior. The causes are multiple and include gunshots, high velocity missiles and knives. The

e(tent of intra-abdominal in"uries may be difficult to predict. However, a high inde( of suspicion

must be maintained to avoid missing occult in"uries.0AThe increased use of 7T scan in patients

with penetrating abdominal in"uries has reduced the rate of negative and unnecessary

laparotomies. +n one study of 0 patients with penetrating abdominal in"ury who underwent 7T,


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@ had laparotomies and all were positive laparotomies. The remaining 0A were managed

conservatively and all had uncomplicated recovery.

H&% C*!r!"%#r1%1"

)bdominal in"uries associated with rapid deceleration at points of ma(imum fi(ation

include tears of the "e"unum at the ligament of TreitE, the terminal ileum and other points of

adhesion. 4ther host related factors thought to influence the response to trauma include age and

pre-e(isting disease. *atients more than B/ years of age e(perience a mortality rate

appro(imately five times than that of younger adults, due to diminished physiologic reserve and

more fragile tissue. )cute ethanol into(ication reduces the physiologic response to stress.

#otor vehicle accidents accounts for B@F of cases of blunt abdominal trauma.

ome series list the liver rather than spleen as the most commonly in"ured intra

abdominal organL this difference probably reflects the means of diagnosis. mall liver in"uries

are often detected in patients who undergo 7T scan of the abdomen, whereas splenic in"uries in

adults are more likely to be clinically significant and reGuire surgical intervention.

TRIAGE AND INJURY SE2ERITY SCORES

This is based on patient stability, mechanism of in"ury and site of in"ury, as well as

diagnostic and therapeutic maneuvers.

The term triage, which is 5rench, was adopted in to the 'nglish language during :orld

:ar +. +t is defined as a process of sorting and classifying sick and in"ured patients, taking into

consideration the nature of in"ury, the resources available, the time to definite care and the

prognosis of the in"uries. Triage is based on the concept that survival will be optimiEed if the

patients needs can be matched with medical resources in a timely way.

INJURY SE2ERITY SCORING

P*y1&&/1"! S"&r#$


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0. %lasgow 7oma cale $%7&.

. Trauma core.

?. Revised Trauma core.

1. *ediatric Trauma core.

@. Therapeutic +ntervention core ystem $T+&

A. )pache +, ++, +++

A!%&1"! S"&r#$

0. )bbreviated +n"ury cale $)+&.

. +n"ury everity core $+&.

GLASGO4 COMA SCALE(GCS5

This widely used scale relates specifically to the head in"ury component of the in"ured

patient. The three aspects of the coma which are specifically assessed are - eye opening ,verbal

response and motor respnse .

>y adding the scores of the three components, the total %lasgow coma scale is determined. The

higher the scores the better the prognosis.

RE2ISED TRAUMA SCORE

7hampion in 0C revised his own trauma score to incorporate the %7. The Trauma core and

Revised Trauma core differ only in that the latter does not include capillary refill or chest

e(pansion.

T!b# 6$ R#81#+ Tr!0! S"&r#

G!/&9 "&! "!# Sy%&1" b&&+ r#0r# R#1r!%&ry r!%# P&1%

6;-6< MC 6=-6> 7


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>-6? BA-C @?> ;

- @/-B@ -> ?

7-< 0-1 6-< 6

; / = =

!ariables on three organ systems that are vital to survival are thus combined into a single

score. High scoring eGuates with better prognosis.

THERAPEUTIC INTER2ENTION SCORE SYSTEM (TISS5 Devised by 7hampion and

introduced in 0B1, this is a method of Gualifying nursing, medical and technological support

activity and calculated for cost. 7urrently it consists of BA procedures. )ssigned a point score of

0 to 1. +t is a non specific score.

ACUTE PHYSIOLOGICAL AND CHRONIC HEALTH E2ALUATION

(APACHE5 SCORE

Devised by 3naus in 0C@. initially it had ?1 variables selected and weighed by clinical

consensus. +t proved unyielding. +n its second version, mandatory physiological variables were

reduced to 0. The score is computed after 1 hours of +7U care, using the worst values recorded

for each of the 0 variables. This reflects risk of death with CAF accuracy. This is used all over

the world.

ABBRE2IATED INJURY SCORE (AIS5 The first anatomic scoring system, )+ was

published in 0B0 as a scoring system for blunt trauma as a result of motor vehicle accidents.0C

ubseGuently there have been si( revisions. The most recent revision in 0/, classified more

than 0?// in"uries into si( levels of in"ury severity.0The scores were originally based on four

criteria2 threat to life, permanent impairment, treatment period and energy dissipation. The

in"uries were further categoriEed into si( different regions. The )+ allows comparisons only

among patients with similar in"uries.


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HISTORY AND PHYSICAL EAMINATION

)s with any surgical disease or emergency, obtaining a careful history and performing a physical

e(amination are of utmost importance in the case of trauma victim.

H1%&ry$ The history taking should never delay providing appropriate care for the e(sanguinating

patient. ) Guick pertinent history of the in"ury should be obtained from the patient or from

family members, bystanders, police and paramedics, important facts include the time of in"ury,

the type and siEe of the wounding agent, the initial vital signs, and the amount of blood loss at

the scene. pecific details of the in"ury mechanism are critical. :hat was the position of the

victim in the vehicle :hat was the type of accident 5rontal impact, side impact, side swipe,

rear impact and rollover have their own uniGue patterns of in"ury. :hat was the siEe and shape of

the weapon, severity of impact forces

4ther important information such as allergies, bleeding tendencies, current medications,

past or present illness, tetanus immuniEation status and the time of the last meal must be

determined. )ll women of childbearing age should be Guestioned about their last menstrual

period and then asked whether they are pregnant.

The severity of mechanism is related to the force and duration of impact as well as the

mass of patient contact area. )ll details regarding pain abdomen, vomiting, retention of urine,

constipation, distention of abdomen etc. should be obtained.

P*y1"! E!1!%1&$

The physical e(amination has always been the most important part. !ital data and signs

of peritoneal irritation are most helpful.

)s the most freGuent signs of intra abdominal in"uries due to blunt trauma are

hypotension or peritonitis, which can occur simultaneously. They might have blood in one of the

four areas viE. the pleural cavities, the peritoneal cavity, the retro peritoneum or e(ternally .

4n inspection of the abdomen it is important to note contusion of skin, particularly in the

areas of lower ribs on either side. 'cchymosis in the flanks, indicating retroperitoneal

haemorrhage should be noted but it may not occur until late. 4n a patient with right sided


24/143

contusions over the lower chest or upper abdominal wall or fractures in the lower si( ribs, in"ury

to the liver should be suspected. +f the same findings are present in the left lower chest or left

upper Guadrant, in"ury to the spleen should be suspected.

There is a /F chance of splenic in"ury and a 0/F chance of hepatic in"ury, with

fractures of left and right lower si( ribs, respectively.

+nspection in penetrating in"ury will reveal entry and e(it wounds, lacerations, abdominaldistension evisceration, impaled ob"ects and sometimes bullet lodged in subcutaneous tissue.

4n palpation, the overt signs of peritonitis may be elicited. Tenderness from abdominal

wall in"ury and intraabdominal in"ury can sometimes be distinguished, if a cooperative patient

can raise his legs several inches off the e(amining table. +f tenderness disappears, in"ury is

intraabdominal. +f tenderness is increased, in"ury is to the abdominal wall. +f the tenderness is

diminished, in"ury to both is present. igns of overt peritonitis may be masked by shock, head

in"ury, spinal in"ury, alcohol or drug ingestion.

)ppro(imately B@F of all penetrating in"uries to abdomen occur in upper Guadrant.

#a"ority are in the left upper Guadrant reflecting the fact that, when two assailants face each

other, the right handed opponent is most likely to inflict left upper Guadrant in"ury. ocation of

wound will help surgeon to gain a rough idea preoperatively of the e(tent of abdominal in"ury.

)bdomen is percussed for the evidence of obliteration or e(tension of liver and spleen

dullness. 5lanks are percussed for the evidence of free fluid in the peritoneal cavity. The absence

of bowel sounds does not necessarily indicate significant intraabdominal in"ury since shock and

trauma to other areas can cause ileus. The progression from the active bowel sound to diminished

and then absent is a more reliable indication. )lso the presence of bowel sounds does not rule out

the possibility of intraabdominal in"ury. +n stable patients, there is a need for repeated abdominal

e(amination, as they may develop peritoneal signs at a later stage

The back, perineum, rectum and vagina should always be e(amined for wounds of

entrance and e(it. ) rectal e(amination is done for blood, crepitus or high floating prostate and

to know the sphincter tone and integrity of the rectal wall. *resence of blood provides evidence


25/143

of colorectal in"ury whereas a flaccid bladder is indicative of spinal cord in"ury in penetrating

trauma.

) valuable sign of continuing intraabdominal haemorrhage is transient elevation of

blood pressure to normal for a few minutes followed by return to hypotensive levels, with rapid

infusion of @//-0///ml of Ringer actate. *atients who are hypotensive due to minimal blood

loss or neurogenic shock do not behave in this manner.

)bdominal e(amination should be completed by inserting nasogastric tube and foleys

catheter.

L&"! 4&0+ E&r!%1&2

+n the stable patient without obvious signs $eg2 peritonitis&, local wound

e(ploration remains a viable screening option. ocal wound e(ploration is a well-defined

procedure done under local anaesthesia to assess whether peritoneal tear is present.

imultaneous wound debridement is done by e(tending the wound as necessary to follow its

track. ocal wound e(ploration is difficult in stab wounds between nipple and costal margin,

which may lead to pneumothora( and stab in back region because of bulky musculature. +f

wound e(ploration is positive or eGuivocal the incidence of negative laparotomy is still @/F.

S 1&r%!% 1/ !r#-

A5 S#!% b#% 1/$

'cchymosis over the lower abdomen, where a lap seat belt has been compressed against

the iliac crest and lower abdomen, indicates that severe force was applied against the abdominal

viscera, especially a distended caecum.

B5 L&+& 1/$

The presence of pattern bruising of the skin, like an imprint of the clothing, indicates that

a crushing force has been applied sufficient to rupture the bowel against the vertebral column.

This sign is a strong indication for laparotomy.

C5 P&1%1/ %#%$


26/143

+t is a sign of great value in ruptured intestine. The sign may locate accurately the site of

perforation.

D5 Gr#y T0r#r 1/$

Discoloration of flanks from retroperitoneal haemorrhage which is noted a few hours

after in"ury.

E5 C0# 1/$

>luish discoloration around the umbilicus.

F5 K#*r 1/$

*ain is referred to the left shoulder due to irritation of the left half of the diaphragm by

splenic blood indicating in"ury to the spleen.

G5 G1b& 1/$

)n e(tremely scaphoid abdomen following blunt trauma to the abdomen, due to

diaphragmatic in"ury.

H5 H!r+# 1/$

aggital compression of sternum causes sharp pain below the left costal arch, positive in splenic

in"ury.

I5 B!!"# 1/$

*ersistent dullness on the left side of the abdomen due to early coagulation of splenic blood and

shifting dullness on the right side indicates in"ury to the spleen.

J5 S&9 B! 1/$

arge amount of blood coagulated in the *ouch of Douglas causes a bulge which retains the

finger mark like a snow ball.

K5 S!#//##r #1" &1%$


27/143

*ressure with finger tip on the phrenic nerve above the clavicle between the stemomastoid and

the scalenus medius on the left side causes violent pain, positive in splenic rupture.

L5 F& 1/$

>luish discoloration below the inguinal ligament indicates retroperitoneal haemorrhage.

DIAGNOSTIC MODALITIES

+nvestigations are essential in the evaluation of abdominal trauma to make accurate

assessment. +n the multiple in"ured patient additional diagnostic modalities may be of significant

benefit.

LABORATORY STUDIES$

>lood studies of value in the initial evaluation include the hematocrit and serum amylase

or lipase.

a& H!#!%&"r1% 8!0#$ reflects a balance of acute blood loss, endogenous plasma refill and

administration of crystalloid.

b& L#03&"y%# "&0%$ leucocytosis following blunt in"ury abdomen is common but non-specific.

c& S#r0 Ay!#$ elevation is indicative of bowel in"ury or pancreatic in"ury but lacks

sensitivity and specificity for intraabdominal in"ury.

d& H#&/&b1 #8#$ erial estimation of hemoglobin percentage should be done to assess the

amount of haemorrhage.

e& P!! A%r!'#r!# #8#$ may be of some value in the diagnosis of liver in"ury

particularly in children.

f& Ar%#r1! b&&+ /! !!y1$ is warranted in intubated patients or those who are at risk for

subseGuent pulmonary decompensation.

Ur1!y1$ detects presence of microscopic hematuria suggestive of asymptomatic urologic

trauma.


28/143

BEDSIDE IN2ESTIGATIONS$

)& Ry# %0b# !1r!%1& 2 aspirated stomach contents are e(amined for the presence of blood

>& Ab+&1! P!r!"#%#12

5our-Guadrant tap was populariEed by Neuhof and 7ohen in 0A and refined by 5itEgerald and

ider in 0A/ to detect intraperitoneal haemorrhage. +t is simple and Guick procedure with

relatively few complications.

T#"*10#$

The abdomen is painted with antiseptic solution. )n 0C% short level spinal needle is

attached to a syringe $preferably 0/ml& and inserted through the abdominal wall, after prior

infiltration of local anaesthetic. uction is applied to the syringe as the needle is slowly advanced

into the abdomen at various sites. Return of a minimum of /.0ml of non-clotting blood is

considered as positive tap.

Pr#"!0%1&$

0. *uncture of rectus sheath should be avoided, for the risk of causing hematoma of rectus

sheath from rupture of epigastric vessels.

. )reas of abdominal scars or other points of bowel fi(ations to the wall should be avoided.

?. Direction of needle inside the abdominal cavity should be changed only by withdrawing

the needle "ust superficial to peritoneum and then reintroducing.

+t should be avoided in the presence of marked bowel distension because of danger of leak

due to increased intraluminal pressure.

DIAGNOSTIC PERITONEAL LA2AGE (DPL5

Root et al described the techniGue of peritoneal lavage in 0A@ and it was further refined

by 4lsen et al in 0B with the addition of Gualitative analysis of the lavage effluent. This is a

rapid, ine(pensive, accurate, relatively safe and reliable procedure for evaluating patients with

blunt in"ury abdomen.


29/143

T#"*1"! !#"%$ the term peritoneal lavage implies washing of peritoneal contentsL one litre

of normal saline is instilled by catheter into peritoneal cavity, recovered by gravity and analyEed.

*receding this is peritoneal aspiration in which an attempt is made to retrieve free intraperitoneal

blood. This finding indicates intraperitoneal organ in"ury and precludes the need for subseGuent

lavage. The techniGue consists of inserting a standard peritoneal dialysis catheter into the

peritoneal cavity, infra umbilically in midline.

7riteria in whom diagnostic peritoneal lavage should be considered are as follows2

- 'Guivocal physical e(amination

- Une(plained shock or hypotension

- )ltered sensorium $closed head in"ury, drugs, etc&

- %eneral anaesthesia for e(tra abdominal procedures

- 7ord in"ury

The contraindications are 2

- 7lear indication for e(ploratory laparatomy

Relative contraindications2

- *revious e(ploratory laparotomy

- *regnancy

- #orbid obesity

- 7oagulopathy

- ignificant haematomas of abdominal wall related to pelvic

fracture

There are three methods of introducing the D* catheter into the peritoneal cavity2

65 C+ %#"*10# $aEarus Nelson&

+t consists of inserting the catheter in a blind percutaneous fashion. +t has been replacedby the much safer but eGually simple eldinger method.

?5 O# %#"*10# $*arrys method&

The open procedure, traversing the abdominal wall under direct visualiEation, is safer but

more time consuming and introduces air into the peritoneal cavity.


30/143

;5 S#1 %#"*10#

+t is Guick, easy and reliable. >efore lavage, the stomach and bladder are decompressed.

The tap is considered positive if greater than 0/ml of blood is aspirated. ) minimum of B@F

lavage effluent is reGuired for the test to be considered valid. The fluid is sent for laboratory

analysis of red and white blood cell counts, amylase and alkaline phosphatase levels and

e(amination for the presence of bile.

C&1"!%1&$

0. :ound complications include dehiscence, infection and hematoma have been cited up to

AF, but occurred in only /.?F in two large series.@

. +atrogenic intraperitoneal in"ury can be inflicted by the catheter, trocar or wire.

*erforation of small and large bowel has been reported most commonly, and bladder and

vascular punctures have occurred.

?. 5inally, large diaphragmatic rents typical of blunt pathophysiology permit flow of lavage

fluid into the thoracic cavity.

I%#rr#%!%1& &' DPL$

avage markers can be categoriEed as2

0. 7ellular - gross blood, R>7, :>7

.'nEymatic - amylase, alkaline phosphatase

?.#iscellaneous - gram stain, bile, vegetable fibers and protein.

T!b# ?$ T*# "r1%#r1! '&r &1%18# DPL '&&91/ b0% 1:0ry !b+.

I+# P&1%18# E018&"!

)spirate >lood

5luid

lavage

M0/ml

'nteric contents

M@ ml


31/143

R>7s

:>7s

'nEyme

>ile

M0,//,/// 8mm?

M@// 8 mm?$ confirmed by repeat D*&

)mylase M/+U8

)lkaline phosphatase M ? +U 8

7onfirmed biochemically

M

@/,/// 8 mm?

M

// 8 mm?

D* sensitivity range from @ - AF, specificity from CC - BF and accuracy BC - CF

RADIOLOGICAL STUDIES$

65 P!1 F1$

)nteroposterior chest radiographs provide clues to associated thoracic and diaphragmatic

in"ury. mall amount of free intraperitoneal or retroperitoneal air may be detectable in patients

with gastric, duodenal, small bowel or colonic perforations. ) search should be made for rib,

pelvic, vertebral body and transverse spus process fractures as these warrant special

consideration for nearby visceral damage.

'(amination of soft tissue shadows may give information concerning alternations of siEe,

shape or position of many viscera. +ndirect evidence of solid visceral rupture with secondary

hemorrhage may be presumed by an increase in density in the region, by displacement of

neighboring viscera or by accumulation of fluid between the gas filled bowel loops. The

appearance of pneumoperitoneum may be facilitated by in"ecting B@/-0///ml, of air into the

nasogastric tube.

)t least C// ml of intraperitoneal blood is reGuired to be evident on plain abdominal

radiograph. 4bliteration of psoas shadow may indicate retroperitoneal hemorrhage. )ppearance

of gas bubbles around duodenal area may indicate its retroperitoneal rupture. The following

findings may be observed2

0. O5lank-stripe signO - fluid dense Eone separating the ascending or descending colon from

a distinctly outlined lateral peritoneal wall, and the colon is displaced medially.


32/143

. ODog-ear signO - results from accumulation of blood that gravitates between the pelvic

viscera and side walls on each side of the bladder.

?. OHepatic angle signO - loss of definition of the usually distinct inferior and right lateral

borders of the liver as accumulates between the hepatic angle and the right peritoneal

wall.

1. O%round glass appearanceO - with e(tensive hemoperitoneum, small bowel may float

towards the center of the abdomen with the production of Oground glass appearanceO.

There may also be loss of psoas shadow or renal shadow in cases of retroperitoneal

hemorrhage.

@. The in"ured spleen may cause displacement of gastric bubble or indentation of the splenic

fle(ure of the colon.

A. +n chest =-rays loops of bowel can occasionally be identified in the chest which is

suggestive of diaphragmatic in"uries.

B. 5ree air under diaphragmn may have entered through the stab wound and may not be

Pbowel airQ. Therefore abdominal films contribute little to evaluation of stab wound of

abdomen

?5 G!%r&/r!''1 C&%r!% S%0+1#$

+t is indicated in case of in"ury to stomach, duodenum and small bowel. +t is a simple,

safe screening test for high risk patient. The procedure consists of instilling @/ ml. of

%astrograffin via. the nasogastric tube then rolling the patient into the right lateral decubitus

position. Radiological sign of duodenal hematoma include defects in the normal contour of the

duodenal loop and obstruction to contrast flow.

;5 I%r!8#&0 Ur&/r!*y$

+ndications for +!U in the initial evaluation of blunt trauma remain unsettled. Theintravenous urogram is a test of function and its main purpose is to identify irreparable

parenchymal disruption as well as renovascular occlusion. %ross hematuria clearly reGuires an

early pyelogram. +!U should be followed by 7T scanning or arteriography for better definition

of poor renal function.

75 R#%r&/r!+# Cy%&/r!$


33/143

+t is useful in patients with suspected urinary bladder in"uries. +t is performed by instilling

radio opaGue fluid $A/ml of ?@F hypaGue or conray with 0/ml of sterile isotonic saline& into

the bladder through a catheter.


34/143

5)T evaluation of the abdomen consists of visualiEation of the pericardium from a

sub(iphoid view, the splenorenal and the hepatorenal spaces $#orisons pouch&, the paracolic

gutters and the *ouch of Douglas in the pelvic. #orisons pouch view has been shown to be the

most sensitive, regardless of the etiology of the fluid.

5ree fluid, generally assumed to be blood in the setting of abdominal trauma, appears as a

black stripe. 5ree fluid in a hemodynamically unstable patient should prompt e(igent

laparotomyL however, the stable patient with free fluid may be further evaluated by 7T scan.

ensitivity and specificity of these studies range from C@-@F.

+ND+7)T+4N 54R UG IN PATIENTS WITH BLUNT TRAUMAABDOMEN

+ndications are the same as for D*. )dditionally it includes2

0. +n stable patients, as an initial method of

scanning, ultrasound may be used to detect a small amount of free intra-peritoneal blood or

intra-parenchymal haemorrhage.

. +n patients with eGuivocal clinical findings or

with indeterminate peritoneal lavage.

?. +n patients in whom D* is contraindicated

such as patients with multiple previous abdominal operations or pregnancy.

1. *atients in whom a diagnosis has been

established by other means $surgicallyL radiologically as 7T scan, radionuclide scanning,

angiography&, for freGuent monitoring and follow up.

There is no absolute contraindication for ultrasound. +maging may be sub- optional in cases with

gross obesity, and acoustic window may not be available in patients with fracture ribs and

associated subcutaneous emphysema. Use of lower freGuency probes may be useful in obese

patients because of greater penetration

5 CT-S"! !b+


35/143

7T scan was added to the surgeons diagnostic armamentarium for blunt abdominal trauma

in the early 0C/s. )lthough initially widely criticiEed for its lack of sensitivity, the accuracy of

7T scans in abdominal tauma has improved with e(perience and a better understanding of what

constitutes abnormal findings. 7T scan has been e(tensively used in recent years for evaluation

of abdominal trauma. +ts usefulness lies chiefly in hemodynamically stable, co-operative

patients, especially if conservative management is planned, and for evaluation of

retroperitoneum. The high cost of eGuipment, time reGuired, radiation e(posure, need for

administration of oral and i.v. contrast, and persistent availability of radiologists having

necessary e(pertise in interpretation of scan are its main drawbacks. *atients co-operation is

reGuired. ) small but significant number of false negative scans has been reported. +t has proved

e(tremely valuable in assessing the retroperitoneum, an anatomic area of in"ury for which D* is

not helpful. 7T should not be performed in unstable patients, who are best evaluated by

e(ploratory laparotomy or D*.

*eitEman and colleagues have listed five indications for abdominal 7T scans in trauma victims2

0. a hemodynamically stable patient with an eGuivocal abdominal e(aminationL

. a patient with close head in"uryL

?. a patient with spinal cord in"uryL

1. hematuria in the stable patientL and

@. patients with pelvic fractures and significant bleeding.

:ith these indications and a patient who is truly hemodynamically stable, the time

reGuired to perform 7T does not delay surgical procedures and e(pensed personnel are available

for immediate interpretation of the results.

The accuracy of 7T ranges from - CF with low false positive and false negative

results.

5 L!!r&"&y (P#r1%&"&y5$

herwood et al in 0C/ modified the techniGue for the trauma patients using eGuipment

that is portable and readily available for use in the emergency room. The procedure is performed

under local anesthesia and employs a miniature laparoscope with an e(ternal diameter of

@mm.'mergency laparoscopy is very useful in blunt abdominal in"uries and is e(tremely helpful


36/143

in avoiding unnecessary abdominal e(ploration. This is a relatively Guick and reliable

investigation and can be done by the surgeon with relatively few complications

5 A/1&/r!*y$

+t is useful in splenic hematoma, kidney and liver in"ures, retroperitoneal hemorrhage,

)! fistula and pseudo aneurysms. Therapeutic selective hepatic artery emboliEation is useful in

controlling hemorrhage from hepatic in"ury. elective infusion of vasoconstrictive drugs can be

used to control gastrointestinal hemorrhages. Haemostatic agents as well as autologous clot may

be used to selectively emboliEe the bleeding vessels. )ngiography is now a time honored

instrument in managing arterial hemorrhage from blunt and penetrating trauma.

>5 I&% S"!1/$

+t is applicable to liver and splenic in"uries. +t provides an evidence for a lesion or a

reassurance of its absence. The radionuclide most freGuently used is technetium sulphur

colloid and can be performed within 0/-0@ minutes.

6=5 M!/#%1" R#&!"# I!/1/ (MRI5$

+t is an e(cellent non-invasive diagnostic aid e(tremely accurate in anatomic definition of

structural in"ury, though costlier to patients.

MANAGEMENT OF ABDOMINAL TRAUMA PATIENTS

#anagement of )bdominal trauma in multiple in"ured patients should take place in

the priority schemes of primary and secondary surveys of patient. +n primary survey, abdomen

should be considered as the site of blood loss in hypotensive patients after attention to airway,

breathing, circulation and e(ternal bleeding.

+n secondary survey, abdomen should be thoroughly e(amined. #anagement

starts in emergency department and includes airway management $if needed&, insertion of largebore intravenous catheter, and administration of intravenous antibiotics and tetanus to(oid

prophyla(is. '(tent of resuscitation depends on haemodynamic stability of the patients.

Those with haemodynamic instability, peritoneal signs, evisceration, %+T bleed

and gunshot wounds with obvious peritoneal penetration should undergo emergency laparotomy.


37/143

+f no indication for immediate laparotomy are present, a more deliberate approach is indicated

and further diagnostic approaches performed.

table patients with stab wounds to anterior abdomen can be managed in different

ways. ocal wound e(ploration is done to rule out peritoneal penetration and patients can be

discharged home after 1 J 1C hours of observation. +f there is peritoneal penetration, peritoneal

tap is performed and is positive, e(ploratory laparotomy is performed. 4therwise patient is

safely observed.

aparoscopy is particularly useful in stab wounds to lower chest or upper abdomen

as none of other investigations are reliable. Those with evidence of peritoneal penetration and

bleeding solid organ can be safely observed. +n patient with stab wound to back or flank,

management by serial observation or by triple contrast 7T can be done and D* is unreliable.

)ll unstable patients and those with peritoneal penetration following gun shot in"uries should

undergo e(ploratory laparotomy.

#anagement of penetrating abdominal trauma in presence of shock or physical

finding of peritoneal irritation should be, immediate laparotomy. Nearly one third of stab wounds

do not penetrate peritoneal cavity and appro(imately @/F that penetrate, cause no significant

in"ury and hence selective conservatism for stab wounds to anterior abdomen is shown to be safe

and effective. ) policy of selective conservatism is advocated patients with no signs or eGuivocal

abdominal findings and haemodynamically stable.

#andatory laparotomy, irrespective of clinical signs is recommended for gunshot wounds

INJURIES TO THE DIAPHRAGM

)ppro(imately ?F of patients with trauma to torso have a diaphragmatic in"ury

identified, with appro(imately two thirds of them secondary to penetrating trauma.

+t occurs from massive increase in the intraabdominal pressure resulting in lacerations

that radiate laterally from the central tendon. B@F of them are left sided because liver protects

the right dome.

#ost common cause of blunt diaphragmatic in"ury is by steering wheel, other causes like

industrial accidents, penetrating in"uries, sports account for only @F of cases.

S1/ &' +1!*r!/!%1" 1:0ry (Br0+#91"*5$


38/143

a. )bsence of respiratory sounds over affected hemi thora(.

b. ) change in position of heart with its displacement to right or left of midline.

c. )bnormal gurgling sounds over affected hemi thora(.

d. ) tympanic note on percussion over affected hemi thora(.

e. Reduced movement over the affected hemi thora(.

f. caphoid abdomen $%ibsons sign&

T!b# ;$ Or/! I:0ry S"!# - +1!*r!/

Gr!+# I:0ry D#"r1%1& )+

I 7ontusion

II aceration cm ?

III aceration - 0/ cm ?

I2 aceration M 0/cm, with tissue loss

@ sG.cm

?

2 aceration with tissue loss M @ sG.cm ?

D1!/&1$

7hest =-ray with in"ection of water soluble contrast medium through nasogastric tube

may confirm the diagnosis. The best radiographic signs of a diaphragmatic defect occur when

herniation is present and include elevation of a hemidiaphragm, contra lateral shift of the

mediastinum, an intrathoracic air bubble or the presence of mass above the diaphragm.

Ultrasonography may demonstrate the right hemidiaphragm as an echogenic curvilinear

structure superior to the liver. ) break in the continuity of this line may signify an in"ury.

7T scan may be able to visualiEe a diaphragmatic defect if it contains herniated

abdominal viscera.


39/143

Diagnostic peritoneal lavage is probably the best non-operative method of diagnosing a

diaphragmatic in"ury. There is almost certainly an in"ury to the diaphragm if lavage fluid e(its

through a thoracostomy tube.

Thoracoscopy and aparoscopy2 4chsner et al found thoracoscopy to be 0//F

diagnostic.

M!!/##%$

During e(ploratory laparotomy, the entire diaphragmatic surface should be e(posed and

directly visualiEed. inear laceration can be repaired with a simple running suture or interrupted

horiEontal mattress sutures using non absorbable material, whereas larger lacerations and tissue

deficits occasionally reGuire repair with prosthetic material. 7are must be taken to avoid

iatrogenic in"ury to the pericardium, heart or lungs.

+f diaphragmatic in"uries are detected more than four weeks after in"ury, they should be

approached through a thoracotomy, so that adhesions to the lung and pleura can be lysed.

Diaphragmatic dysfunction is commoner after repair of large blunt in"uries and may reGuire

prolonged ventilatory support.

4ccasionally the diaphragm with a large chronic defect has atrophied and retracted and

primary repair is not possible. +n such cases, a prosthetic material such as marle( or prolene

mesh may be necessary to close the defect.

INJURIES TO THE ABDOMINAL 4ALL

The abdominal wall contracts when it receives a force thus protecting the viscera inside

but the muscle, fascia and skin take the whole brunt. +n"ury to the abdominal wall without

intraperitoneal in"ury is difficult to diagnose. Types of in"uries of abdominal wall are2 )brasions,

contusions, lacerations and hematomas.

#uscular guarding and rigidity are freGuently present. )bdominal breathing is

diminished over the part. 7orresponding to the site of rupture a bulge of considerable siEe

appears. Tenderness increases on leg raising test if it is a parietal wall in"ury but decreases in

case of intraabdominal in"ury. Hematomas are usually due to rupture of rectus abdominis or


40/143

epigastric arteries. To distinguish this mass from intraabdominal mass, leg raising test should be

carried out.

+f owing to the lesion of posterior rectus sheath, the bowel is pushed forward between the

edges of the torn rectus, the palpatory finding is slightly reminiscent of chronic hernia of the

abdominal wall. The most important aspect of differential diagnosis is to e(clude the lesions of

abdominal cavity. +n purely parietal lesions, the general condition of the patient does not

deteriorate. '(ception is the rupture of epigastric artery. *arietal wall in"ury is never associated

with paralytic ileus.

acerations and abrasions need wound debridement, suturing and dressing. arge

hematoma needs evacuation and ligation of bleeders. Rupture of muscle reGuires immediate

operative intervention.

INJURY TO SOLID ORGANS

SPLEEN

+t is the most commonly in"ured intraabdominal organ in blunt trauma. plenic in"ury

following penetrating trauma is less. +n"ury is suspected whenever there is a blow, fall or sports

in"ury to the left chest $with or without fractures of left lower ribs&, flanks or left upper abdomen.

4nce regarded as Omysterii pleni organonO, the spleen is now considered an important

immunologic factory as well as reticuloendothelial filter. Routine splenectomy remained the

treatment of choice for splenic in"ury. :ith increase in recognition of the haEards of asplenic

state, a more conservative approach to splenic in"ury is now preferred.

Diseased spleen as in infectious mononucleosis, malaria, leukemia, hemolytic anemia,

congestive splenomegaly and polycythemia vera may rupture due to a trivial trauma.

D##+1/ 0& %*# "11"! !1'#%!%1& r0%0r# &' ## 1 "!1'1#+ ! '&&9$

a& A"0%# r0%0r#$ The patient succumbs rapidly, never recovering from the initial shock.

Tearing of the splenic vessels and complete avulsion of the spleen from its pedicle gives rise to

rapid blood loss which can be fatal within minutes.


41/143

b& S0b !"0%# r0%0r#$ +nitial shock, recovery from shock, signs of a ruptured spleen is the

usual type of presentation. )fter the initial shock has passed off, there are signs which point to

intraabdominal bleeding.

c& D#!y#+ %y#$ )fter the initial signs have passed off, the symptoms of a serious

intraabdominal catastrophe are postponed for a variable period of up to two weeks or more. The

delayed type of splenic rupture was described by >audet in 0/ and the asymptomatic interval

between in"ury and rupture is known as Othe latent period of >audetO.

The cause of delayed hemorrhage is local vasoconstriction with or without the formation of

blood clot which seals the tear. The causes of hemorrhage are those of reactionary or secondary

hemorrhage.

C11"! F#!%0r#$

+f the patient complains of pain associated with respiration, suspicion of splenic rupture is

heightened. ) ruptured spleen seems even more likely if the left 0/ or 00 thrib is fractured, a

diagnosis best made during physical e(amination by gentle, careful palpation along the course of

the ribs.

plenic in"ury is always suspected if any penetrating in"ury to left upper Guadrant or left

flank. *enetrating in"ury to spleen cause significant bleeding. The history and physical

e(amination continue to be the basis from which splenic in"ury is diagnosed.

*hysical e(amination has an accuracy of A?F. There is an increasing pallor, a rising

pulse rate, sighing respiration and restlessness. )bdomen may be distendedL tenderness and

guarding may be generaliEed or localiEed to left upper Guadrant. eft lower ribs may be

fractured. ocal bruising may be present in left upper Guadrant.

3ehrs sign, pain at the tip of the shoulder, may be elicited by pressure in the left upper

Guadrant by placing the patient in the Trendelenburg position. >allances sign, fi(ed dullness to

percussion in the left upper Guadrant may be appreciated. Tenderness may be elicited at the

aeggessers splenic point i.e. on phrenic nerve above the clavicle between the sternomastoid and

the scalenus medius on the left side.


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hifting dullness may be present at the flanks. Rectal e(amination freGuently reveals

tenderness and sometimes a soft swelling due to blood or clots in the rectovesical pouch i.e. the

Onow >all signO.

I8#%1/!%1&$

0& aboratory evaluation can demonstrate a wide variability in the hematocrit, increase in the

leukocyte count. ) base deficit ? meG8 obtained from )>% analysis suggests significant

hemorrhage.

.*lain =-ray abdomen2 radiological signs of splenic rupture are 'levation of the left

hemidiaphragm, obliteration of the splenic shadow,obliteration of psoas shadow,enlargement of

splenic shadow, medial displacement of the gastric bubble because of the accumulation of clot in

the gastrosplenic ligament, widening of the space between the splenic fle(ure and preperitoneal

pad of fat, fracture of one or more ribs on the left side $present in BF of cases&

?& Ultrasonography 2 The spleen can usually be visualiEed and a surrounding hematoma may

suggest rupture. erial e(amination by showing a change in splenic siEe can identify an enlarging

sub capsular hematoma.

1& 7T scan 2 especially essential if non-operative therapy is planned. plenic lacerations appear

as irregular intrasplenic low density regions. The paracolic gutters, subhepatic space and cul-de-

sac should be e(amined for the presence of free intraperitoneal blood.

@& Radionuclide scans 2 using technetium sulfur colloid, collections of blood within the splenic

parenchyma will compress the surrounding tissues and produce focal areas of decreased uptake.

A& )rteriography 2 Direct signs include e(travasation or pooling of contrast material in the

parenchyma, arteriovenous shunting or pseudo aneurysm formation.

*eritoneal avage2 This is a rapid, ine(pensive, accurate, relatively safe and reliable procedure to

detect hemoperitoneum. +t has an accuracy rate of @-CF.

T!b# 7$ Or/! I:0ry S"!# - S##$


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Gr!+# I:0ry D#"r1%1&

I Haematoma ub capsular, non-e(panding 0/F surface area

aceration 7apsular tear, lcm parenchymal depth

II Haematoma ub capsular, 0/-@/F surface area, intraparenchymal,

@cm diameter.

aceration 0-? cm parenchymal depth which does not involve a

trabecular vessel.

III Haematoma ub capsular M@/F of surface area or e(panding, ruptured

sub capsular hematoma with active bleeding.

+ntraparenchymal hematoma M@cm or e(panding.

aceration M?cm parenchymal depth or involving trabecular vessels.

I2 Haematoma Ruptured intraparenchymal hematoma

aceration +nvolving segmental or hilar vessels producing ma"or

devascularisation $M@F spleen&

2 aceration 7ompletely shattered spleen

!ascular Hilar vascular in"ury which devascularises spleen.

M!!/##%$

Non-operative #anagement2

7lass +, ++ or +++ splenic in"uries may be candidates for non-operative management if there is2

0& No hemodynamic instability after initial fluid resuscitation

& No serious associated intra-abdominal in"ury.


44/143

?& 1 hour availability of emergency 7T scan, 4.T. and surgeon round the clock.

These patients are managed in the surgical intensive care unit on complete bed Rest with

close monitoring by repeated physical e(amination and serial hematocrits. )n empiric 1-A weeks

of convalescence with reduced activity for ? months has been recommended.

4perative #anagement2

The principle goal of operation for splenic in"ury is to control bleeding. ) midline

incision provides rapid and e(cellent access to the management of splenic in"ury. 7omplete

mobiliEation of the spleen is the key to adeGuate assessment of in"ury and safe repair. The lerenal

and phrenicoleinal ligaments are avascular and can be incised away from lateral margin of the

spleen. !essels in lecolic ligament are ligated and divided. pleen is rotated into the wound by

bluntly dissecting the plane posterior to the pancreas and anterior to the %erotas fascia. Then

short gastric vessels in the gastroleinal ligament should be divided.

)fter adeGuate mobiliEation, clots over spleen are removed by gentle irrigation or

grasping with forceps. )fter adeGuate mobiliEation and clot removal, severity of in"ury is

assessed. 5urther operative management depends on the assessment of degree of in"ury to the

spleen.

0& %rade + in"ury 2 generally reGuire little treatment $Tamponade, topical hemostat& or no

treatment.

%rade ++ in"ury2 can be treated with haemostatic agents $including microfibrillar collagen,

gelfoam soaked in topical thrombin or surgicel& with tamponade to control bleeding.

?& %rade +++ in"ury 2 various techniGues have been described. The principles are removal of clot

and devitaliEed tissue, complete reappro(imation of parenchymal edges to the depth of the

wound to avoid leaving dead space and suture placement within the fibrous capsule well away

from the wound margin to prevent tearing. '(panding sub capsular hematoma should be opened,

the clot evacuated and a diligent search made for parenchymal arterial bleeding, which can be

controlled with suture ligature.


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1& %rade +! in"ury 2 often reGuires partial splenectomy. Hemostasis is attained by selected

ligation of the appropriate segment artery. Debridement is accomplished by finger fracture or

sharp resection at the line of demarcation. The resected splenic surface is treated with a

combination of through and through capsular suture and haemostatic agents. )n omental pedicle

may be used to seal raw surface. Use of an absorbable mesh wrap has been described. Topical

and intraparenchymal in"ections of fibrin glue $a mi(ture of fibrgen thrombin, aprotinin and

calcium chloride& have produced hemostasis in cases with deep splenic in"ury and coagulopathy.

@& %rade ! in"ury 2 splenectomy should be performed.other indications of plenectomy 0. +f

splenorrhaphy is unsuccessful in other grades, .rupture of diseased spleen and ?.multiple intra

abdominal in"uries with hypotension.

Routine drainage of the splenic bed is not used for either splenectomy or splenorrhaphy.

+f there is associated in"ury to tail of pancreas, closed suction drainage is employed. *olyvalent

pneumococcal vaccine should be administered immediately after splenectomy, to prevent the risk

of overwhelming pneumococcal sepsis.

C&1"!%1&2

0. Hemorrhage - *rimary and reactionary

. eft lower lobe atelectasis, pneumonia $especially left lower lobe& left pleural effusions.

?. %astric complications - gastric dilatation and fistula, gastric necrosis when the short

gastric vessels are ligated ad"acent to the stomach.

1. Haematemesis,

@. ubphrenic abscess,

A. Thrombocytosis. plenectomy increase the platelet count by ?/F

B. *ancreatitis - The overall incidence is F following splenectomy

C. +nfection - 'arly infection occurs in appro(imately @F of patients. :ound infection

occurs in @F of patients who have had splenectomy for trauma.

O8#r9*#1/ P&% S##"%&y I'#"%1& (OPSI5 has been defined by Diamond as a

fulminant bacterial illness that usually progresses to death within 1 hours of recognition and

does not always e(hibit the usual prodromal signs of infection. 5ollowing splenectomy, young

children are particularly at high risk to develop fulminant infections due to treptococcus


46/143

pneumoniae, H. influenEa and Neisseria meningitides. )ll patients of splenectomy should be

given polyvalent pneumococcal vaccine. 7hildren should also receive the H. influenEa type >

!accine.

#ortality 2 4verall mortality following splenic in"ury is 0/F. #orbidity correlates with degree

of associated in"ury.

LI2ER

>ecause of its siEe and location in the abdominal cavity, the liver is freGuently in"ured in

penetrating in"ury and is the second most commonly in"ured organ following blunt trauma. +n

pregnancy, sickle cell anemia, primary hepatocellular carcma and hepatic adenoma, the liver

may be fragile and fractured by a mr blow.

+t may result from direct blows, compression between the lower ribs on the right and

spine or shearing at fi(ed points secondary to deceleration. fractures of the lower ribs on the right

freGuently accompany blunt trauma to the liver.

C11"! F#!%0r#$

)ll lower chest stabs on the right side and upper abdominal stab wounds should be

suspect, especially if considerable blood volume replacement has been reGuested. imilarly crush

in"ury to right lower chest or upper abdomen, often combine rib fracture, haemothora( and

damage to liver.) subcutaneous emphysema or ecchymosis on abdominal skin should greatly

arouse suspicion of blunt trauma.

*atient can present with profound hypotension, temporarily responsive to the infusion of

blood and fluids. *atient can have abdominal distension, guarding, rigidity and tenderness in the

right hypochondrium. The area of liver dullness may be enlarged. 7ompression of the lower end

of the sternum elicits tenderness over the lower coastal arch. There may be hemothora( on right

side.

I8#%1/!%1&$


47/143

0. *lain =-ray of abdomen - may reveal fracture of vertebrae and right lower ribs,

hemothora( on right side, elevation of right dome of diaphragm, increased liver shadow,

obscured psoas shadow and concomitant in"uries with free or retroperitoneal air.

. U% of abdomen - Useful in tracking of parenchymal or sub capsular hematoma and

appro(imate loss of blood into the peritoneal cavity.

?. D* - 5or hemoperitoneum, accurate in /F of cases

1. +sotope scanning - The radionuclide most freGuently used is Technetium sulphur

colloid.

@. 7T scan - +t is highly sensitive and specific in defining the presence of an intra-hepatic

hematoma or hepatic laceration and the appro(imate volume of blood loss into the

peritoneal cavity.

A. )ngiography - 5or diagnostic purpose and therapeutic purpose of hepatic artery

emboliEation.

T!b#


48/143

I2 aceration *arenchymal disruption involving @-B@F hepatic lobe or 0-?

7ouinaud segments

2 aceration *arenchymal disruption involving MB@F of hepatic lobe or M?

7ouinaud segments within a single lobe

!ascular 9u(tahepatic venous in"uries $i.e., retrohepatic venecava 8 central

ma"or hepatic veins&

2I !ascular Hepatic avulsion

M!!/##%

Non operative management criteria2

Hemodynamic stability

)bsence of peritoneal signs

Neurological integrity

7T can delineation of in"ury

)bsence of associated intra abdominal in"uries

Need for not more than hepatic related blood transfusions

7T scan documented improvement or stabiliEation with time

4perative #anagement

+ndications2

0. tab or gunshot wounds that have penetrated the abdomen

. igns of peritonitis

?. *atients with une(plained shock, uncontrolled heamorrhage or clinical deterioration

during observation.1. )ssociated other intraabdominal in"uries.

The abdomen should be rapidly opened and a Guick appraisal of bleeding sites made. )ll blood

clots and debris should be removed rapidly by scooping them out. Temporary control of bleeding

sites may be obtained by placement of packs and the use of manual compression. ) Guick


49/143

e(ploration should be carried out of the liver, spleen and ma"or vessels. +f ma"or bleeding from

the liver is noted, compression of the portal triad between the thumb and inde( finger to include

the hepatic artery and portal vein $*ringle maneuvre& may be useful ad"unct to packs and manual

compression. )n atraumatic clamp may be placed across the hepatoduodenal ligament. +f these

fail, a simple hepatic tourniGuet may be constructed by using a large De >akey aortic clamp and

a penrose drain.

The aorta is to be temporarily occluded "ust below the diaphragm using manual

compression with an aortic compressor of the hand of an assistant, when persistent hemorrhage

is found and continues in spite of the use of packing and the *ringles maneuvre, in"ury to hepatic

vein or retro hepatic venecava is likely. +n this situation, control of infra and supra hepatic

venacava must be obtained. They may then be temporarily occluded. This is a last resort

temporiEing maneuver, since occlusion of inferior venacava impedes A/F of the blood return to

the right atrium and may lead to further deterioration of the patient. Recently, the use of various

intracaval shunts has alleviated this problem. The method is that described by 6ellis, consisting

of a number C endotracheal tube with multiple side holes cut into it and inserted through a purse

string suture in the right atrial appendage@1.

65 Dr!1!/#

%rades + and ++ in"uries make up C@F of all liver in"uries. +n the past most surgeons

agreed that all liver in"uries should drained, however this has recently been challenged.

?5 S0%0r1/

Hemorrhage from grade ++ liver in"uries can usually be halted by the placement of heavy

mattress sutures $0-/ or -/& of an absorbable material on a blunt tipped liver needle. +f

buttressing is necessary, the use of omentum is preferred.

;5 L1/!%0r# &' B##+1/ P&1%

Directly ligate the bleeding points with suture or surgical hot clips. 'lectrocautery may be

useful in obtaining hemostasis in the diffuse ooEe. )lternatively application of one of the topical

haemostatic agents like o(idiEed cellulose $surgicel& and gelatin sponge $%elfoam&.

75 D#br1+##%


50/143

)nother important aspect of treatment is the debridement of the non viable parenchyma.

This does not imply a formal resection, but rather it is carried out along the planes of in"ury


51/143

there is e(tensive damage isolated to one lobe of the liver . The techniGue of resection is similar

to that used in elective resection. The use of cell-saver device may limit the need for transfusion

and the recently developed ultrasonic aspirator $7U)& described by Hodgson may be helpful.

%rade ! in"uries are rare. These in"uries can often be managed by primary repair and an

intracaval shunt is necessary only in the e(treme situation.

C&1"!%1&$

0.Hemorrhage,.Respiratory insufficiency, ?..7oagulopathy, 1..Hypoglycemia ,@.>iliary fistula

or other bile duct in"ury, A.Hemobilia,B.ub diaphragmatic or intraparenchymal abscess

formation ,C.Hypoalbuminemia,.Transient hyperbilirubinemia,

PANCREATIC TRAUMA

The *ancreas, because of its close pro(imity to lumbar vertebrae, is more susceptible to

crushing in"uries due to direct blow or seat belt in"uries. +ncidence of in"uries to this organ is 0/-

0F of all abdominal in"uries. >ecause of its retroperitoneal location, symptoms are usually

delayed.

*enetrating in"uries to pancreas is associated with mortality rate of ?-?F. *ancreas is

rarely in"ured in isolation and occur in F patients, because of its location. Therefore, ma"ority

of its associated mortality is due to haemorrhage and other associated in"uries

The site of in"ury is prognostically important because damage to the pancreatic head has a

mortality rate double that of either body or tail in"ury.

C11"! F#!%0r#$

oft tissue contusion in the upper abdomen away from bony prominences indicates that a

significant force has been dissipated in this areaL epigastric pain out of proportion to the

abdominal e(amination is often due to a retroperitoneal in"ury.

I8#%1/!%1&$

0. erum )mylase - neither sensitive nor very specific for pancreatic in"ury.


52/143

. D* - estimation of amylase in peritoneal fluid.

?. Radiography

i. *lain =-ray abdomen may reveal obliteration of psoas shadow, retroperitoneal air

along psoas margin or upper pole of right kidney or pleural effusion and elevated

diaphragm, especially with in"ury to tail of pancreas. +n later stages, there may be

ground glass appearance.

ii. Upper %.+. studies with water soluble contrast media may show, widening of 7-loop of

duodenum, abnormal displacement of stomach and colon and sometimes leakage of

contrast medium.

1. )ngiography - may reveal splenic vein thrombosis and portal hypertension.

@. Ultrasound - not helpful in the acute phase, helpful during follow-up for the development of

pseudocyst or abscess formation.

A. 'ndoscopic retrograde cholangio pancreaticography $'R7*& - for ductal disruption.

B. 7T scan - will reveal early pseudocysts, mild traumatic pancreatitis, pancreatic contusions,

lacerations and fractures with high degree of accuracy.

C!1'1"!%1&$

ucas developed the following classification for pancreatic in"ury 2 7lass +2

7ontusions or abrasions to the pancreas but not involving the main ducts. 7lass ++2 evere distal

pancreatic laceration or disruption with suspected ductal in"ury. 7lass +++2 7lass ++ type of in"ury

only to pro(imal rather than distal pancreas. 7lass +!2 evere combined pancreaticoduodenal

in"ury.

M!!/##%$

The following are the key principles for the management of pancreatic in"ury.

0. 7ontrol hemorrhage and control bacterial contamination.

. Debride devitaliEed pancreatic tissue.


53/143

?. *reserve at least /-@/F of functional pancreatic tissue whenever possible

1. *rovide adeGuate internal or e(ternal drainage of pancreatic in"uries or resections.

7lass +2 '(ternal drainage, infreGuent distal pancreatectomy.

7lass ++2 Distal pancreatectomy

7lass +++2 Distal pancreatectomy or Rou(-en-6 pancreatico"e"unostomy

7lass +!2 Repair 8 e(clude duodenum, treat pancreas as 7lass +, ++, and +++.

*ancreaticoduodenectomy.

C&1"!%1&$

0. 5istula - in @ to F of patients

. econdary Hemorrhage - @-0/F

?. *ancreatitis - occurs in less than @F of patients

with in"ury.

1. *seudocyst - about .@F, more common after

non-operative management.

+n most series, there is up to @F mortality rate that occurs early, as a result of associated

vascular in"uries.

ETRAHEPATIC BILLARY TRACT

+n"uries to gall bladder and e(trahepatic biliary tract are rare with incidence of 0.1F.

%all bladder is commonly in"ured part and attributed to its superficial location and larger siEe.

#ortality rate for e(trahepatic biliary tract varies between 1F - 00F and depends on associated

in"ury. #ortality rate can be @/F when biliary in"ury is associated with vascular in"ury.

C11"! Pr##%!%1&$


54/143

*atient may present with shock due to chemical peritonitis caused by bile which leads to

outpouring of fluids into peritoneal cavity. )bsorption of bile salts may cause cholaemia,

bradycardia is a valuable diagnostic sign.

I8#%1/!%1&$

Diagnosis of in"uries to the e(trahepatic biliary tract is rarely made preoperatively. +t is

usually made intra operatively.

0. *eritoneal tap 8 D* positive for bile salt or pigments.

. Radionuclide hepatobiliary imaging with Technetium m.

T!b# $E%r!*#!%1" B11!ry Tr!"% 1:0ry S"!# $

Gr!+# D#"r1%1&

I %all >ladder contusion8Haematoma. *ortal triad

contusion8Haematoma.

II *ortal %all >ladder avulsion from liver bedL cystic duct intact,

laceration or perforation of %all bladder.

III 7omplete gall bladder avulsion from liver bed, cystic duct

laceration

I2 *artial or complete right hepatic duct laceration.

*artial or complete left hepatic duct laceration.

*artial common hepatic duct laceration $ @/F&.

2 *artial common hepatic duct laceration $M @/F&. M

@/F transection of common hepatic duct.

M @/F transection of common bile duct.


55/143

M!!/##%$

The treatment depends on general condition of the patient and on the e(tent of damage to gall

bladder.

(A5 I:0r1# %& /! b!++#r !+ "y%1" +0"%$

0. imple suture 8 cholecvstorrhaphv2 This can be employed for mr in"uries. +t is not

recommended now days because of the risk of bile leakage.

7holecystectomy2 +s indicated if the general condition of the patient is satisfactory and there is

avulsion of gall bladder from liver bedL e(tensive laceration or in"ury to pathological gall

bladder, for in"ury to cystic duct or if right hepatic artery is ligated for haemorrhage control and

in gunshot in"uries

7holecystostomy 2 +ndications are

$a& :hen general condition is not satisfactory

$b& There are severe associated in"uries

$c& :hen anatomy of biliary tree is obscured by in"ury.

(B5 I:0r1# %& b1# +0"% $

0. *artial bile duct in"uries2 mall lacerations can probably be closed without a T-tube . +n"uries

with less than @/F tissue loss along the medial or posterior aspect of the duct can be repaired

primarily using @-/ vicryl.

. in"uries to left and right hepatic duct2 +n unstable patient, ligation of either duct can be

performed. +f the patient is stable, then a Rou(-en-6

?. +n"uries to common hepatic duct2 The standard approach is hepatico"e"unostomy.

1. +n"uries to common bile duct2 +n"ury to the supra and retro duodenal portions of the 7>D can

be managed by cholecysto"e"unostomy, choledochoduodenostomy can be used for more distal

in"uries of the common bile duct. +f there is significant destruction to the surrounding tissues

including the duodenum, then a pancreaticoduodenectomy is advised.


56/1

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Abt for Corrections 22CORRECTIONS-10