Upload
hidayat-shariff
View
40
Download
5
Tags:
Embed Size (px)
Citation preview
Resuscitation & Abdominal trauma
Presenter : Muhammad AfifAnis Zarina
Supervisor : Dr Wazir
OutlineDEFINITION AND INTRODUCTION
ASSESSMENT & RESUSCITATION
DEFINITIVE CARE
TAKE HOME MESSAGES
DEFINITION AND INTRODUCTION
• TRAUMA – cellular disruption caused by environmental energy / physical force
• 6th leading cause of death worldwide(10% of cases)
• Leading cause of death in those aged 5 to 40 years
• Majority of trauma cases is due to road traffic accidents (70.1%)
Trauma related death has a trimodal distribution
A) Death due to massive injuries. Seconds to minutes.
B) Death due to hemorrhage. Hours.
C) Death due to late complications of trauma. Days to weeks.
*golden hour – in the 1st hour, 30% of death takes place
Lethal triad of death in trauma
Severe haemorrhage → hypovolemic shock → Hypothermia +
coagulopathy+ acidosis 3 factors aggravate each
otherin a vicious cycle → further bleeding → intractable shock→ death
Assessment and resuscitation•Primary survey with concurrent
resuscitation.•Requires a team of doctors, nurses,
assistant medical doctors and attendants.•Must be lead by a team leader.•Secondary survey with concurrent
resuscitation.•Reassessment and on going resuscitation
while reviewing investigations.
Primary Survey•A = Airway maintenance with cervical
protection – intubate if necessary.•B = Breathing and ventilation – Look for
signs of respiratory distress and SPO2. ▫Non invasive or invasive oxygen therapy
with relief of life threatening conditions eg tension pneumothorax.
•C = Circulation with hemorrhage control▫2 large bore 16 Gauge branula, CBD, CVP▫IV crystalloids 30ml/kg run fast▫Stop external bleeder▫Colloids and blood products.▫Aim MAP 65mmHg
•D = Disability ,neurological status•E = Exposure / environmental control
Evaluation of fluid resuscitation•The return of normal blood pressure,
pulse pressure and pulse rate•Improvements in CNS status and skin
circulation . •Urine Output : 0.5-1ml/kg/h•CVP•Acid base balance
▫Persistent metabolic acidosis is usually due to inadequate resuscitation or ongoing blood loss.
After fluid bolus is given..Rapid response Transient response No response
Vital signs Return to normal Transient improvement
Remain abnormal
Estimated blood loss
Minimal (10-20%) Moderate and ongoing (20-40%)
Severe (>40%)
Need for more crystalloid
Low High High
Need for blood Low Moderate to high Immediate
Blood preparation Type and cross match
Type – specific Emergency blood release
Need for operative intervention
Possibly Likely Highly likely
Need for immediate surgical intervention
No No Yes
Transient or non responder•Most common: ongoing internal bleeding
- clinically : more pallor, persistent tachycardic, tachypnea, abd distension- FAST scan- Aggressive fluid resuscitation (using 3:1 rule)- Blood transfusion : 2pint pack cell
*consider DIVC regime
Secondary Survey•Follows the primary survey•Complete history including AMPLE•Complete head -to-toe examination•Reassessment of response to
resuscitation.
ExaminationInspection Palpation Auscultation
Distended Tenderness Bowel sounds -absent -in thorax
Abrasion Guarding
Laceration Rigidity
Cullen’s, Grey turner’s, Kehr’s sign
Mass
Gross hematuria PR – high riding prostate
Hematoma or bruises
Cullen’s sign
Grey turner’s sign
Kehr’s sign
Investigations
•Serial FBC, RP, PT/INR, ABG, Serum amylase
•FAST US•X-ray chest and abdomen•USG Abdomen•CT scan
Focused Assessment with Sonography in Trauma (FAST)• To detect hemoperitoneum & pericardial effusion• Sensitivity 86- 99%• Four different views:
-Pericardiac -Perihepatic -Perisplenic -Peripelvic
Advantages of FAST• Can detect 100 mL of blood
• Rapid , accurate, portable, reproducible
• Cost effective, non invasive, no radiation
• Eliminates unnecessary CT scans
• Helps in management plan
Plain X-ray chest & AbdomenCXR:• Free air under diaphragm• NG tube or bowel loops in the thoracic cavity• Elevation of both or single diaphragm• Lower ribs fractures
AXR:• Ground glass appearance-massive
hemoperitoneum• Obliteration of psoas shadow-retroperitoneal
bleed
CT scan
•Gold standard •High sensitivity and specificity-95%•Provides excellent imaging of solid and
hollow organs, retroperitoneum, genitourinary system (able to grade) and hemo/pneumoperitoneum.
•Determines the source of bleeder.•Can reveal other associated injuries eg
vessels.•Only in haemodynamically stable patients.
ABDOMINAL TRAUMA
MECHANISM OF INJURY
Blunt trauma Penetrating injury
Fall from height Stab wound
MVA Gunshot wound
Domestic injury
Sport injury
Contact injury
Child abuse
Abdominal injuries•Intraperitoneal • Solid, hollow, mesentery
•Retroperitoneal•Abdominal wall (hematoma) esp in
warfarinized or hemophilia patients after minor trauma.
Intraperitoneal
•Solid organs▫Spleen(40-55%)▫Liver(35-45%)
•Hollow organs ▫Gastric, bowel, bladder or GB perforation▫Penetrating injury
•Mesentery (bowel ischaemia)
Retroperitoneal
•Pancreas (10-20%) – traumatic pancreatitis
•Vascular(5-10%) – major vessels•Kidneys(5%)
Indications for laparotomy
•Blunt abdominal trauma + hypotension + positive FAST or clinical evidence of intraperitoneal bleeding
•Penetrating trauma : eg : Gunshot or abdominal evisceration
•Peritonitis •Free air, retroperitoneal air or rupture of
hemidiaphragm after blunt trauma•Organ specific injury - on CT scan
Splenic injury•20% due to left lower rib fractures
Conservative Management:▫Hemodynamic stable▫Negative abdominal examination▫Absence of contrast extravasation in CT▫Subcapsular Hematoma, Laceration <3cm
•Serial abdominal examination and CT scan.•Success rate of conservative Mx >80%
Operative management
•Splenorrhaphy with serial monitoring.•Total Splenectomy and vaccination.•Success rate of splenic salvage procedure
is 40-60%.•Others – partial splenectomy, total
splenectomy with autotransplantation.
Liver injury
•Largest organ - 2nd most commonly injured
•85% with blunt hepatic trauma are stable•CT – main stay of diagnosis in stable
patient•Most treated conservatively•Watch out for on going bleed, hepatic
necrosis, infected billoma, biliary tree injuries.
Conservative management
•Haemodynamically stable•No other intra abdominal injury require
surgery•< 2 units of blood transfusion required in
6 hours•Hemoperitoneum <500ml on CT
Operative management
•Liver packing- Bleeding can be stopped- Pack removed after 48hr
•Pringle’s maneuver- Direct compression of the portal triad
(digitally or soft clamp) to control the inflow
• Lobar Resection •Liver Transplantation
Renal injury
•Clinically not suspected & frequently overlooked
•Clinical - Shock, hematuria & pain over the loin
•Urine: gross or microscopic hematuria•CT scan – Grading
Management
•85% of blunt renal trauma can be manage conservatively.
•Indications for nephrectomy▫Hemodynamic instability▫Grade 5 renal injury
•Risk of dialysis should be explained if planned for nephrectomy.
Take home messages• Primary survey and resuscitation goes
hand in hand. It’s an ongoing process.• Coagulopathy, hypothermia, and
worsening metabolic acidosis are lethat triad that need to be watched out for in trauma patients• Fluid resuscitation is vital and evaluation
of it is important.• Negative FAST scan cannot exclude
possibility of significant intraabdominal injury if clinically is indicated.
•CT scan is gold standard to diagnose intraabdominal injury in hemodynamically stable patient.
•20% of splenic injury is due to lower rib fractures
•85% with blunt hepatic trauma are stable•85% of blunt renal trauma can be manage
conservatively
References
•ATLS for Doctors, 9th edition•Bailey & Love Short Practice of Surgery,
25th edition•http://www.surgeons.org.uk/advanced-tra
uma-life-support/shock.html•Clinical companion in surgery
•Thank you!