Abdominal truma 2007

Presented by :Presented by :Dr. Rashid AbuelhassanDr. Rashid Abuelhassan

ABDOMINAL TRUMAABDOMINAL TRUMA

15/3/200815/3/2008

Blunt Abdominal trauma Blunt Abdominal trauma DPLDPL Penetrating abdominal trauma Penetrating abdominal trauma Diagnostic ProceduresDiagnostic Procedures Intra abdominal injuries Intra abdominal injuries

– Diaphragm injuries Diaphragm injuries – Liver trauma Liver trauma – Kidneys traumaKidneys trauma– Pancreas traumaPancreas trauma– Stomach traumaStomach trauma– DuodenalDuodenal– Small bowel Small bowel – Colon Colon – Splenic ruptureSplenic rupture

____________________________________Refrences:Refrences:1- www.webMD.com2- 2- www.eMedicine.com

Tutorial outline Tutorial outline

http://www.webmd.com/

1) Blunt Abdominal Truma 1) Blunt Abdominal Truma IntroductionIntroduction

CausesCauses motor vehicle collisionsmotor vehicle collisions AssaultsAssaults recreational accidentsrecreational accidents falls. falls.

The most commonly injured organs are The most commonly injured organs are spleen, liver, retroperitoneum, small bowel, kidneys, spleen, liver, retroperitoneum, small bowel, kidneys,

bladder, colorectum, diaphragm, and pancreas. bladder, colorectum, diaphragm, and pancreas.

statisticsstatistics In 2005, approximately 5 million people died In 2005, approximately 5 million people died

worldwide as a result of injury .worldwide as a result of injury .

Globally, injury accounts for 10% of all deaths; Globally, injury accounts for 10% of all deaths; however, injuries in sub-Saharan Africa are far more however, injuries in sub-Saharan Africa are far more destructive than in other areas .destructive than in other areas .

Estimates indicate that by 2020, 8.4 million people Estimates indicate that by 2020, 8.4 million people will die yearly from injury, and injuries from traffic will die yearly from injury, and injuries from traffic collisions will be the third most common cause of collisions will be the third most common cause of disability worldwide and the second most common disability worldwide and the second most common cause in the developing world. cause in the developing world.

1) Blunt abdominal truma1) Blunt abdominal truma

pathophysiologypathophysiology

Blunt force injuries to the abdomen can Blunt force injuries to the abdomen can generally be explained by 3 mechanisms:generally be explained by 3 mechanisms:1.1. rapid deceleration causes differential rapid deceleration causes differential

movement among adjacent structures movement among adjacent structures 2.2. crushed between the anterior abdominal wall crushed between the anterior abdominal wall

and the vertebral column or posterior thoracic and the vertebral column or posterior thoracic cage cage

3.3. rise in intra-abdominal pressure and culminate rise in intra-abdominal pressure and culminate in rupture of a hollow viscous organ in rupture of a hollow viscous organ


Advanced Trauma Life Support protocol Advanced Trauma Life Support protocol

AAirway, with cervical spine precautions irway, with cervical spine precautions BBreathing reathing CCirculation irculation DDisability isability EExposurexposure


Clinical ActClinical Act

Clinical ActClinical Act History: History: (should be quick while doing ABCs)(should be quick while doing ABCs)

– The extent of vehicular damage The extent of vehicular damage – Whether prolonged extrication was required Whether prolonged extrication was required – Whether the passenger space was intruded Whether the passenger space was intruded – Whether a passenger died Whether a passenger died – Whether the person was ejected from the Whether the person was ejected from the

vehicle vehicle – The role of safety devices such as seat belts The role of safety devices such as seat belts

and airbags and airbags – The presence of alcohol or drug use The presence of alcohol or drug use – The presence of a head or spinal cord injury The presence of a head or spinal cord injury – Whether psychiatric problems were evidentWhether psychiatric problems were evident


Points to remember Points to remember – Allergies Allergies – Medications Medications – Past medical and surgical history Past medical and surgical history – Time of last meal Time of last meal – Immunization status Immunization status – Events leading to the incident Events leading to the incident – Social history, including history of substance Social history, including history of substance

abuse abuse – Information from family and friendsInformation from family and friends– patient should be examined repeatedly and patient should be examined repeatedly and

at frequent intervalsat frequent intervals


Symptoms and signsSymptoms and signsAsk AboutAsk About

PainPain TendernessTenderness gastrointestinal hemorrhagegastrointestinal hemorrhage HypovolemiaHypovolemia evidence of peritoneal irritation evidence of peritoneal irritation

The abdomen is examened for The abdomen is examened for abrasions or ecchymosisabrasions or ecchymosis The seat belt sign The seat belt sign abdominal distention abdominal distention Grey Turner sign Grey Turner sign Cullen sign Cullen sign Auscultation of bowel Auscultation of bowel Palpation Palpation A rectal examination A rectal examination


Points to Be in MindPoints to Be in Mind DPL is indicated in blunt trauma as follows:DPL is indicated in blunt trauma as follows:

Patients with a spinal cord injury Patients with a spinal cord injury Those with multiple injuries and unexplained shock Those with multiple injuries and unexplained shock Obtunded patients with a possible abdominal injury Obtunded patients with a possible abdominal injury Intoxicated patients in whom abdominal injury is suggested Intoxicated patients in whom abdominal injury is suggested Patients with potential intra-abdominal injury who will undergo Patients with potential intra-abdominal injury who will undergo

prolonged anesthesia for another procedure prolonged anesthesia for another procedure

immediate blood transfusion is indicated in hemodynamic immediate blood transfusion is indicated in hemodynamic instability despite the administration of 2 L of fluid to adult instability despite the administration of 2 L of fluid to adult patients; this instability indicates ongoing blood loss.patients; this instability indicates ongoing blood loss.

Indications for laparotomy in a patient with blunt abdominal Indications for laparotomy in a patient with blunt abdominal injury include the following:injury include the following:

Signs of peritonitis Signs of peritonitis Uncontrolled shock or hemorrhage Uncontrolled shock or hemorrhage Clinical deterioration during observation Clinical deterioration during observation Hemoperitoneum findings after FAST or DPL examinations Hemoperitoneum findings after FAST or DPL examinations


The only The only AbsoluteAbsolute contraindication contraindication to DPL is the obvious need for to DPL is the obvious need for laparotomy. laparotomy.

RelativeRelative contraindications include contraindications include morbid obesity, a history of multiple morbid obesity, a history of multiple abdominal surgeries, and pregnancy. abdominal surgeries, and pregnancy.


About DPLAbout DPL

DPL is considered positiveDPL is considered positive in a blunt trauma patient with 10 mL of in a blunt trauma patient with 10 mL of grossly bloody aspirate obtained before grossly bloody aspirate obtained before infusion of the lavage fluid or infusion of the lavage fluid or if the siphoned lavage fluid (ie, 1 L if the siphoned lavage fluid (ie, 1 L normal saline infused into the peritoneal normal saline infused into the peritoneal cavity via a catheter and allowed to mix, cavity via a catheter and allowed to mix, which is then drained by gravity) has which is then drained by gravity) has more than 100,000 RBC/mL, more than more than 100,000 RBC/mL, more than 500 WBC/mL, elevated amylase content, 500 WBC/mL, elevated amylase content, bile, bacteria, vegetable matter, or urinebile, bacteria, vegetable matter, or urine

Only approximately 30 mL of blood is Only approximately 30 mL of blood is needed in the peritoneum to produce a needed in the peritoneum to produce a

microscopically positive DPL result microscopically positive DPL result


Methods of DPLMethods of DPL

1. Open2. Semiopen3. closed methods


Lab Workup CBC & coagulation studies, blood type, and blood CBC & coagulation studies, blood type, and blood

cross-match cross-match Urine studies include urinalysis, urine toxicologic Urine studies include urinalysis, urine toxicologic

screen, and serum or urine pregnancy tests in screen, and serum or urine pregnancy tests in females of appropriate age. females of appropriate age.

Serum electrolyte values, creatinine level, and Serum electrolyte values, creatinine level, and glucose values are often obtained for reference glucose values are often obtained for reference

The serum lipase or amylase level is neither The serum lipase or amylase level is neither sensitive nor specific as a marker for major sensitive nor specific as a marker for major pancreatic or enteric injury pancreatic or enteric injury

All patients should have their tetanus All patients should have their tetanus immunization history reviewed. If it is not current, immunization history reviewed. If it is not current, prophylaxis should be given. prophylaxis should be given.


Imaging StudiesImaging Studies Plain radiographPlain radiograph Ultrasound Ultrasound

(70 mL of blood could be detected, while 30 mL (70 mL of blood could be detected, while 30 mL is the minimum requirement for detection with is the minimum requirement for detection with

ultrasound )ultrasound ) Computed tomography Computed tomography Laparoscopy Laparoscopy


TreatmentTreatment ABCsABCs Nonoperative management

– strategies on CT scan diagnosis and the hemodynamic stability of the patient are now being used in the treatment of adult solid organ injury

– Angiography is a valuable modality in the Angiography is a valuable modality in the nonoperative management of adult abdominal nonoperative management of adult abdominal solid organ injuries from blunt traumasolid organ injuries from blunt trauma


Surgical TreatmentSurgical Treatment• When laparotomy is indicated, broad-

spectrum antibiotics are given • After intraperitoneal injuries are

controlled, the retroperitoneum and pelvis must be inspected.

• Do not explore pelvic hematomas • observation, and hemoperitoneum findings

after FAST or DPL examinations• After the source of bleeding has been

stopped, further stabilizing the patient with fluid resuscitation and appropriate warming is important


complicationcomplication Complications associated with BAT Complications associated with BAT

includes but are not limited to the includes but are not limited to the following:following:– Missed injuries Missed injuries – Delays in diagnosis Delays in diagnosis – Delays in treatment Delays in treatment – Iatrogenic injuries Iatrogenic injuries – Intra-abdominal sepsis and abscess Intra-abdominal sepsis and abscess – Inadequate resuscitation Inadequate resuscitation – Delayed splenic rupture Delayed splenic rupture


2) Penetrating abdominal truma2) Penetrating abdominal trumaIntroductionIntroduction

Penetrating abdominal injury implies that either:•A GSW •A stab wound has violated the abdominal cavity.

PathophysiologyPathophysiology GSW is caused by a missile propelled by GSW is caused by a missile propelled by

combustion of powder. combustion of powder. – These wounds involve high-energy transfer and, These wounds involve high-energy transfer and,

consequently, can have an unpredictable pattern of consequently, can have an unpredictable pattern of injuries. injuries.

– Secondary missiles, such as bullet and bone fragments, Secondary missiles, such as bullet and bone fragments, can inflict additional damage. can inflict additional damage.

– Military and hunting firearms have higher missile Military and hunting firearms have higher missile velocity than handguns, resulting in even higher energy velocity than handguns, resulting in even higher energy transfertransfer

– Close-range shotgun injuries often cause significant Close-range shotgun injuries often cause significant tissue damage and should be considered high-energy tissue damage and should be considered high-energy transfer injuries as welltransfer injuries as well

2) Penetrating abdominal truma2) Penetrating abdominal truma

PathoPathophysiologyphysiology ofof GSWGSW

GSWs are associated with a high GSWs are associated with a high incidence of intra-abdominal injuries. incidence of intra-abdominal injuries. Nearly all patients with GSWs require Nearly all patients with GSWs require laparotomy laparotomy

Patients without recordable cardiac Patients without recordable cardiac activity upon presentation should not activity upon presentation should not be further resuscitated.be further resuscitated.


Stab wound Stab wound Stab wounds are caused by penetration of Stab wounds are caused by penetration of

the abdominal wall by a sharp object. This the abdominal wall by a sharp object. This type of wound generally has a more type of wound generally has a more predictable pattern of organ injury. predictable pattern of organ injury. However, occult injuries can be However, occult injuries can be overlooked, resulting in devastating overlooked, resulting in devastating complications. complications.

associated with a significantly lower associated with a significantly lower incidence of intra-abdominal injuries; incidence of intra-abdominal injuries; therefore, expectant management is therefore, expectant management is indicated in hemodynamically stable indicated in hemodynamically stable patientspatients

2) Penetrating abdominal truma2) Penetrating abdominal trumaPathoPathophysiologyphysiology ofof Stab woundsStab wounds

Clinical AssesmentClinical Assesment Assessment of the patient begins at the scene of the Assessment of the patient begins at the scene of the

incident by emergency medical service (EMS) personnel incident by emergency medical service (EMS) personnel

1.1. Physical examination includes inspection of all body Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds. Multiple surfaces, with notation of all penetrating wounds. Multiple wounds may represent entrance or exit wounds and must wounds may represent entrance or exit wounds and must not be labeled as such, since multiple missiles or foreign not be labeled as such, since multiple missiles or foreign objects may be retained within the bodyobjects may be retained within the body

2.2. signs, such as pain and guarding and signs, such as pain and guarding and rebound tenderness, which necessitate exploration rebound tenderness, which necessitate exploration without delaywithout delay


3. Abdominal distension in an unresponsive patient may 3. Abdominal distension in an unresponsive patient may indicate active internal bleeding that also requires indicate active internal bleeding that also requires exploration, especially in combination with hypotension. exploration, especially in combination with hypotension.

4. Rectal examination is performed on all patients with PAT, as 4. Rectal examination is performed on all patients with PAT, as blood per rectum and high-riding prostate can indicate blood per rectum and high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively. bowel injury and genitourinary tract injury, respectively. Notation of blood at the urethral meatus is also a sign of Notation of blood at the urethral meatus is also a sign of genitourinary tract injury.genitourinary tract injury.

5. When immediate operative intervention is not requisite, 5. When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing and further evaluation ensues with laboratory testing and diagnostic and imaging studiesdiagnostic and imaging studies


Diagnostic ProceduresDiagnostic Procedures Nasogastric intubationNasogastric intubation

Blood in the nasogastric tube can indicate upper Blood in the nasogastric tube can indicate upper gastrointestinal injury gastrointestinal injury

Foley catheterizationFoley catheterization Blood in the nasogastric tube can indicate upper Blood in the nasogastric tube can indicate upper

gastrointestinal injury gastrointestinal injury Diagnostic peritoneal lavage Diagnostic peritoneal lavage

closed method closed method open method open method Semi open methodSemi open method

Tube thoracostomyTube thoracostomy Rigid sigmoidoscopyRigid sigmoidoscopy


Initial treatment Initial treatment At least 2 large-bore peripheral At least 2 large-bore peripheral

intravenous catheters should be secured intravenous catheters should be secured Fluids should be administered rapidlyFluids should be administered rapidly Arterial access for continuous blood Arterial access for continuous blood

pressure monitoring is standard pressure monitoring is standard warm blankets and prewarmed fluids. warm blankets and prewarmed fluids.

Antibiotics should be administered to Antibiotics should be administered to patients undergoing exploration patients undergoing exploration


Preoperative detailsPreoperative details The patient is placed in the supine The patient is placed in the supine

position with arms extended position with arms extended The entire chest, abdomen, and The entire chest, abdomen, and

pelvis, including the upper thighs, pelvis, including the upper thighs, are prepped and draped are prepped and draped

Entering the abdominal cavity can Entering the abdominal cavity can release tamponade, resulting in a release tamponade, resulting in a precipitous drop in blood pressure, precipitous drop in blood pressure,


Intra operatively Intra operatively

Goals :Goals :1.1. control of bleedingcontrol of bleeding2.2. identification of injuriesidentification of injuries3.3. control of contaminationcontrol of contamination4.4. reconstruction (if possible). reconstruction (if possible).


Diphragm InjuriesDiphragm Injuries

Classifiction :Classifiction :(I) Contusion(I) Contusion(II) laceration, <2 cm(II) laceration, <2 cm(III) laceration, 2-10 cm(III) laceration, 2-10 cm(IV) laceration, >10 cm(IV) laceration, >10 cm(V) total tissue loss, >25 cm2 (V) total tissue loss, >25 cm2


LiverLiver Injuries Injuries (I) nonbleeding capsular tears, <1 cm (I) nonbleeding capsular tears, <1 cm

deepdeep (II) lacerations, 1-3 cm deep and <10 cm (II) lacerations, 1-3 cm deep and <10 cm

longlong (III) laceration, >3 cm deep(III) laceration, >3 cm deep (IV) parenchymal disruption involving 25-(IV) parenchymal disruption involving 25-

75% of a lobe or 1-3 segments75% of a lobe or 1-3 segments (V) parenchymal disruption of >75% of a (V) parenchymal disruption of >75% of a

lobe or >3 segments or juxtahepatic lobe or >3 segments or juxtahepatic venous injuryvenous injury

(VI) hepatic avulsion. (VI) hepatic avulsion.


Operative management of liver injuries can involve many Operative management of liver injuries can involve many techniquestechniques– including simple packing or wrappingincluding simple packing or wrapping– local hemostasislocal hemostasis– resectional debridementresectional debridement Packing may successfully control minor hemorrhage; however, packs Packing may successfully control minor hemorrhage; however, packs

may need to be left in place and the abdomen closed temporarily. may need to be left in place and the abdomen closed temporarily.

Several hemostatic agents have been used in liver repair:Several hemostatic agents have been used in liver repair:– including thrombin fibrin sealantincluding thrombin fibrin sealant– collagen/gel preparationscollagen/gel preparations– electrocauteryelectrocautery– argon beam argon beam – radiofrequency coagulationradiofrequency coagulation– omental packingomental packing– even intrahepatic balloon tamponade as in the case of through-and-even intrahepatic balloon tamponade as in the case of through-and-

through injuriesthrough injuries– Resectional debridement is much less commonly required in the Resectional debridement is much less commonly required in the

treatment of penetrating liver injuries but may be accomplished with treatment of penetrating liver injuries but may be accomplished with finger fracture, cautery, sutures, clips, or stapler device.finger fracture, cautery, sutures, clips, or stapler device.


Kidney Kidney InjuriesInjuries (I) contusion; (II) lacerations, <1 cm; (I) contusion; (II) lacerations, <1 cm;

(III) lacerations, >1 cm; (IV) (III) lacerations, >1 cm; (IV) lacerations to the collecting system; lacerations to the collecting system; and (V) vascular avulsion. and (V) vascular avulsion.


PancreasPancreas Grades I and II include superficial or major Grades I and II include superficial or major

laceration or contusion without ductal laceration or contusion without ductal injury, respectively. Grade III injuries are injury, respectively. Grade III injuries are distal transections without duct injury or distal transections without duct injury or tissue loss. Grade IV lacerations involve tissue loss. Grade IV lacerations involve proximal transection or parenchymal proximal transection or parenchymal injury involving the ampulla. Grade V injury involving the ampulla. Grade V injuries are massive disruptions of the injuries are massive disruptions of the pancreatic head.pancreatic head.


StomachStomach Injuries Injuries opening of the gastrocolic ligament, opening of the gastrocolic ligament,

which allows entrance into the lesser which allows entrance into the lesser sac. Injuries extending into the sac. Injuries extending into the lumen may be repaired quickly with lumen may be repaired quickly with a stapling device. a stapling device.


DuodenumDuodenum (I) hematoma; (II) partial thickness (I) hematoma; (II) partial thickness

laceration; (III) laceration disrupting <50% laceration; (III) laceration disrupting <50% circumference of D1, D3, D4, or 50-75% circumference of D1, D3, D4, or 50-75% circumference of D2; (IV) laceration circumference of D2; (IV) laceration disrupting 50-100% circumference of D1, disrupting 50-100% circumference of D1, D3, D4, or >75% circumference of D2, or D3, D4, or >75% circumference of D2, or involving the ampulla or distal common involving the ampulla or distal common bile duct; and (V) massive disruption of the bile duct; and (V) massive disruption of the duodenopancreatic complex or duodenopancreatic complex or devascularization of the duodenum.devascularization of the duodenum.


Small bowelSmall bowel Control of contamination is of high Control of contamination is of high

priority with penetrating injuries to priority with penetrating injuries to the small bowel. Clamps or staples the small bowel. Clamps or staples may be used for temporary control may be used for temporary control as the entire length of the small as the entire length of the small bowel is examined. bowel is examined.


ColonColon The management of colonic injuries The management of colonic injuries

depends on the extent of the defect, depends on the extent of the defect, the amount of contamination, and the amount of contamination, and the stability of the patient. Primary the stability of the patient. Primary repair may be considered if the repair may be considered if the patient is hemodynamically stable patient is hemodynamically stable and if the injury is fairly small with and if the injury is fairly small with minimal fecal contamination minimal fecal contamination


Early postoperative complications include Early postoperative complications include ongoing bleeding, coagulopathy, and ongoing bleeding, coagulopathy, and abdominal compartment syndrome. The abdominal compartment syndrome. The latter is treated with opening of the latter is treated with opening of the abdomen and temporary closure. abdomen and temporary closure.

Later complications include acute Later complications include acute respiratory distress syndrome, pneumonia, respiratory distress syndrome, pneumonia, sepsis, intra-abdominal fluid collections, sepsis, intra-abdominal fluid collections, wound infections, and enterocutaneous wound infections, and enterocutaneous fistulae.fistulae.

Late complications include small bowel Late complications include small bowel obstruction and incisional hernias.obstruction and incisional hernias.


Spleen InjuriesSpleen Injuries The spleen, weighing 75-150 g, is a highly The spleen, weighing 75-150 g, is a highly

vascular organ that filters an estimated vascular organ that filters an estimated 10-15% of total blood volume every 10-15% of total blood volume every minute. The spleen may hold 40-50 mL of minute. The spleen may hold 40-50 mL of red cells in reserve on average; however, red cells in reserve on average; however, with changes in internal smooth muscle, it with changes in internal smooth muscle, it can pool significantly more blood can pool significantly more blood

EtiologyEtiology penetrating trauma penetrating trauma blunt trauma blunt trauma explosive type injuries explosive type injuries


pathophysiologypathophysiology Though normally protected by its anatomic Though normally protected by its anatomic

position, preexisting illness or disease can position, preexisting illness or disease can markedly increase the risks and severity of markedly increase the risks and severity of splenic injury. Infectious mononucleosis, malaria, splenic injury. Infectious mononucleosis, malaria, and hematologic abnormalities can lead to acute and hematologic abnormalities can lead to acute or chronic enlargement of the spleen. This is or chronic enlargement of the spleen. This is often accompanied by a thinning of the capsule, often accompanied by a thinning of the capsule, making the spleen more fragile as well as making the spleen more fragile as well as engendering a greater mass effect in decelerating engendering a greater mass effect in decelerating trauma. Minor impact in patients with trauma. Minor impact in patients with splenomegaly reportedly results in major injury splenomegaly reportedly results in major injury and the need for splenectomy and the need for splenectomy


Clinical featuresClinical features The clinical presentation of splenic injury is highly The clinical presentation of splenic injury is highly

variable. Most patients with minor focal injury to variable. Most patients with minor focal injury to the spleen complain of right upper quadrant the spleen complain of right upper quadrant abdominal tenderness. Left shoulder tenderness abdominal tenderness. Left shoulder tenderness may also be present as a result of may also be present as a result of subdiaphragmatic nerve root irritation with subdiaphragmatic nerve root irritation with referred pain. referred pain.

With free intraperitoneal blood, diffuse abdominal With free intraperitoneal blood, diffuse abdominal pain, peritoneal irritation, and rebound pain, peritoneal irritation, and rebound tenderness are more likely. If the intra-abdominal tenderness are more likely. If the intra-abdominal bleeding exceeds 5-10% of blood volume, clinical bleeding exceeds 5-10% of blood volume, clinical signs of early shock may manifestsigns of early shock may manifest


Signs include tachycardia, tachypnea, Signs include tachycardia, tachypnea, restlessness, and anxiety. Patients may have a restlessness, and anxiety. Patients may have a mild pallor noted only by friends and family. mild pallor noted only by friends and family. Clinical signs include decreased capillary refill Clinical signs include decreased capillary refill and decreased pulse pressure. With increasing and decreased pulse pressure. With increasing blood loss into the abdominal cavity, abdominal blood loss into the abdominal cavity, abdominal distension, peritoneal signs, and overt shock may distension, peritoneal signs, and overt shock may be observed. be observed.

Hypotension in a patient with a suspected splenic Hypotension in a patient with a suspected splenic injury, especially if young and previously healthy, injury, especially if young and previously healthy, is a grave sign and a surgical emergency. is a grave sign and a surgical emergency.


Indications of surgical interventionIndications of surgical intervention In simple terms, unstable patients suspected of In simple terms, unstable patients suspected of

splenic injury and intra-abdominal hemorrhage splenic injury and intra-abdominal hemorrhage should undergo exploratory laparotomy and should undergo exploratory laparotomy and splenic repair or removal. A blunt trauma patient splenic repair or removal. A blunt trauma patient with evidence of hemodynamic instability with evidence of hemodynamic instability unresponsive to fluid challenge with no other unresponsive to fluid challenge with no other signs of external hemorrhage should be signs of external hemorrhage should be considered to have a life-threatening solid organ considered to have a life-threatening solid organ (splenic) injury until proven otherwise. Transient (splenic) injury until proven otherwise. Transient responders, those patients who respond to an responders, those patients who respond to an initial fluid bolus only to deteriorate again with a initial fluid bolus only to deteriorate again with a drop in blood pressure and increasing drop in blood pressure and increasing tachycardia, are also likely to have solid organ tachycardia, are also likely to have solid organ injury with ongoing hemorrhage injury with ongoing hemorrhage


In the stable trauma patient, In the stable trauma patient, commonly defined as a patient with commonly defined as a patient with systolic blood pressure greater than systolic blood pressure greater than 90 mm Hg with a heart rate less than 90 mm Hg with a heart rate less than 120 beats per minute (bpm), CT 120 beats per minute (bpm), CT scanning provides the most ideal scanning provides the most ideal noninvasive means for evaluating the noninvasive means for evaluating the spleen. spleen.


Imaging studyImaging study Radiography Radiography

– Chest radiograph is obtained on all because penetration of the chest cavity cannot be ruled out, even with abdominal stab wounds or even-numbered GSWs patients

– Abdominal radiographs in 2 views (ie, AP, lateral) are also obtained on all patients with GSWs to help determine missile trajectory and to account for retained missiles in patients with odd-numbered GSWs.

– The focused assessment with sonography for trauma (FAST) uses 4 views of the chest and the abdomen


CT scan is used in the evaluation of CT scan is used in the evaluation of patients with stab wounds to the flank and patients with stab wounds to the flank and the back and in the evaluation of selected the back and in the evaluation of selected patients with abdominal stab wounds and patients with abdominal stab wounds and GSWs GSWs

Intravenous Pylogram is more often used Intravenous Pylogram is more often used intraoperatively to assess contralateral intraoperatively to assess contralateral renal function in a patient with kidney renal function in a patient with kidney damage necessitating nephrectomy damage necessitating nephrectomy


Diagnostic procedureDiagnostic procedure Diagnostic peritoneal lavageDiagnostic peritoneal lavage

– DPL is a method of rapidly determining if free DPL is a method of rapidly determining if free intraperitoneal blood is present. This test is intraperitoneal blood is present. This test is especially useful in the hypotensive patient.especially useful in the hypotensive patient.

– DPL is fast and inexpensive. It has a low DPL is fast and inexpensive. It has a low complication rate in experienced hands.complication rate in experienced hands.

– FAST has replaced DPL in many institutions FAST has replaced DPL in many institutions because it is less invasive, but it has not yet because it is less invasive, but it has not yet been shown to be more sensitive or specific been shown to be more sensitive or specific than DPL in most published studiesthan DPL in most published studies


Lab workupLab workup All patients should undergo certain basic laboratory testing, All patients should undergo certain basic laboratory testing,

as follows: as follows: Complete blood count (CBC) provides a baseline value for Complete blood count (CBC) provides a baseline value for

later comparison, even though it may not reveal the extent later comparison, even though it may not reveal the extent of active bleeding. of active bleeding.

Basic chemistry profile (BMP) also reveals any baseline Basic chemistry profile (BMP) also reveals any baseline renal insufficiency or electrolyte abnormalities. renal insufficiency or electrolyte abnormalities.

Coagulation studies (PT/INR + PTT) may suggest Coagulation studies (PT/INR + PTT) may suggest development of coagulopathy. development of coagulopathy.

Arterial blood gas (ABG) provides important information Arterial blood gas (ABG) provides important information regarding acid-base balance and, thus, the hemodynamic regarding acid-base balance and, thus, the hemodynamic stability of the patient. stability of the patient.

Urine dipstick may reveal occult blood indicative of Urine dipstick may reveal occult blood indicative of genitourinary tract injuries. Female patients should have genitourinary tract injuries. Female patients should have urine pregnancy testingurine pregnancy testing


treatmenttreatment

1)Medical1)Medical The trend in management of splenic injury

continues to favor nonoperative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable hemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years. For instances in which patients have significant injury to other systems, surgical intervention may be considered even in the presence of the previously noted findings.


2)Interventional radiology2)Interventional radiology

Splenic angioembolization is increasingly being used in both stable responders and transient responders for fluid resuscitation under constant supervision by a surgeon with an operating room on standby


3) Surgical Therapy3) Surgical Therapy Surgical therapy is usually reserved for Surgical therapy is usually reserved for

patients with signs of ongoing bleeding or patients with signs of ongoing bleeding or hemodynamic instability. In some hemodynamic instability. In some institutions, CT scan–assessed grade V institutions, CT scan–assessed grade V splenic injuries with stable vitals may be splenic injuries with stable vitals may be observed closely without operative observed closely without operative intervention, but most patients with these intervention, but most patients with these injuries will undergo an exploratory injuries will undergo an exploratory laparotomy for more precise staging, laparotomy for more precise staging, repair, or removal repair, or removal


In less emergent situations, splenorrhaphy is the In less emergent situations, splenorrhaphy is the preferred method of surgical care. Multiple preferred method of surgical care. Multiple techniques are described in the literature, but techniques are described in the literature, but they all attempt to tamponade active bleeding they all attempt to tamponade active bleeding either by partial resection and selective vessel either by partial resection and selective vessel ligation or by putting external pressure on the ligation or by putting external pressure on the spleen via an absorbable mesh bag or sutures. spleen via an absorbable mesh bag or sutures. Both “make it yourself” and commercial products Both “make it yourself” and commercial products are available for this purpose. In patients with are available for this purpose. In patients with capsular injury, the electrocautery or argon beam capsular injury, the electrocautery or argon beam coagulator device may provide adequate coagulator device may provide adequate hemostasis and allow for splenic preservation. hemostasis and allow for splenic preservation.


PostoperativePostoperative appropriate antibiotics for 5-7 days appropriate antibiotics for 5-7 days arteriography with embolization can be used to stop arteriography with embolization can be used to stop

the small percentage of arterial bleeding found in the small percentage of arterial bleeding found in pelvic fractures pelvic fractures

Follow-upFollow-up closely monitor vital signs and frequently repeat the closely monitor vital signs and frequently repeat the

physical examinationphysical examination “ “ An increased temperature or respiratory rate can An increased temperature or respiratory rate can

indicate a viscus perforation or abscess formation. indicate a viscus perforation or abscess formation. Pulse and blood pressure can also change with sepsis Pulse and blood pressure can also change with sepsis or intra-abdominal bleeding. The development of or intra-abdominal bleeding. The development of peritonitis based on physical examination findings is peritonitis based on physical examination findings is an indication for surgical intervention. an indication for surgical intervention.

2) Penetrating abdominal truma2) Penetrating abdominal truma2) Penetrating abdominal truma2) Penetrating abdominal truma

COMPLICATIONSCOMPLICATIONS Complications of nonoperative care include delayed Complications of nonoperative care include delayed

bleeding, splenic cyst formation, and splenic necrosis. bleeding, splenic cyst formation, and splenic necrosis. Complications of splenorrhaphy include rebleeding and Complications of splenorrhaphy include rebleeding and thrombosis of the residual spleen as well as complications thrombosis of the residual spleen as well as complications related solely to the laparotomy. related solely to the laparotomy.

Complications of splenectomy include bleeding from short Complications of splenectomy include bleeding from short gastrics or splenic vessels and the most feared but most gastrics or splenic vessels and the most feared but most rare complication, infection by encapsulated organisms rare complication, infection by encapsulated organisms such as such as PneumococcusPneumococcus. .

Material used for compression wrap of the spleen in Material used for compression wrap of the spleen in splenorrhaphy is often woven and may mimic bubbles in an splenorrhaphy is often woven and may mimic bubbles in an abscess on postoperative CT scans. Gel foam used for abscess on postoperative CT scans. Gel foam used for angioembolization may also falsely mimic an abscess on CT angioembolization may also falsely mimic an abscess on CT scans. Communication with the radiologist about the scans. Communication with the radiologist about the presence of splenic wrapping material on any postoperative presence of splenic wrapping material on any postoperative CT scans will decrease the chance of this false-positive CT scans will decrease the chance of this false-positive resultresult


Angioembolization of the spleen can result in Angioembolization of the spleen can result in noninfectious-related febrile events, sympathetic noninfectious-related febrile events, sympathetic pleural effusions, and left upper quadrant pleural effusions, and left upper quadrant abscesses. Femoral arteriovenous fistulas and abscesses. Femoral arteriovenous fistulas and iliofemoral pseudoaneurysms have also been iliofemoral pseudoaneurysms have also been reported (Killeen, 2001; Ekeh, 2005). reported (Killeen, 2001; Ekeh, 2005).

Posttraumatic splenic pseudocysts are being Posttraumatic splenic pseudocysts are being reported more frequently now that nonoperative reported more frequently now that nonoperative management has become the norm (Wu et al, management has become the norm (Wu et al, 2006). Optimal management is still unknown but 2006). Optimal management is still unknown but probably requires partial or complete probably requires partial or complete splenectomy to minimize morbidity and mortalitysplenectomy to minimize morbidity and mortality


Thrombocytosis with platelet counts above Thrombocytosis with platelet counts above 1 million/mm3 have been linked to 1 million/mm3 have been linked to thrombotic vascular events such as deep thrombotic vascular events such as deep vein thrombosis, pulmonary embolus, or vein thrombosis, pulmonary embolus, or occlusive stroke. Although very little good occlusive stroke. Although very little good data exist, many surgeons treat persistent data exist, many surgeons treat persistent thrombocytosis with a daily baby aspirin. thrombocytosis with a daily baby aspirin.

Pancreatic injury, pancreatitis, subphrenic Pancreatic injury, pancreatitis, subphrenic abscess, gastric distension, and focal abscess, gastric distension, and focal gastric necrosis have also been reported gastric necrosis have also been reported after splenectomy for trauma. after splenectomy for trauma.


Thanks for your attention …Thanks for your attention …

Dr. Aamer Jalal Othman HamzaDr. Aamer Jalal Othman Hamza

Health & Medicine

Abdominal truma 2007