Unformatted text preview: Trauma: Abdomen,
Shalini Arora, PGY 3
January 5th, 2006 36 year old man, restrained driver in rollover
motor vehicle crash. Blood pressure on
arrival is 83/57 and HR 102. Hypotension
unresponsive to resuscitation. Tender
abdomen. Abdominal ultrasound obtained.
abdomen. Next step?
d. Exploratory laparotomy
Diagnostic peritoneal lavage
Abdominal CT scan
Serial observation 28 y/o woman, unrestrained driver in a motor
vehicle crash. Stable vital signs and LUQ
tenderness, but no signs of peritonitis.
a. Exploratory laparotomy
b. Diagnostic peritoneal lavage
c. Serial observation
d. Abdominal CT scan
e. Abdominal ultrasonography Abdomen
q 25% of all trauma patients require ex lap.
Physical exam can be unreliable
– AMS, compensated hemoperitoneum, retroperitoneal,
pelvic q Diagnostic tools:
– Diagnostic peritoneal lavage (DPL)
Test of choice dependent on hemodynamic
stability and severity of associated injuries.
q Stable blunt trauma → FAST or CT
q Unstable blunt trauma → FAST or DPL
q Stab wounds without peritoneal signs,
evisceration, or hypotension → wound
exploration or DPL.
q Gun shot wounds → surgical exploration.
q Standard criteria
– q 10cc gross blood
RBC>100,000/mm2 (5% miss)
Bile, bacteria, or food Contraindications
– Clear indication for ex lap
Prior abdominal surgeries
Obesity *NGT, foley DPL
q Highly sensitive to intraperitoneal blood, but low
specificity → nontherapeutic explorations.
Supraumbilical if pelvic fracture present
Significant injuries may be missed
Renal, pancreatic, duodenal
Extraperitoneal bladder injuries
Extraperitoneal Focused Assessment with
Sonography for Trauma (FAST)
– Low cost q Cons
– User dependent
Obesity, gas interposition
Misses retroperitoneal/hollow viscus injury
May not detect free fluid <50-80 cc CT Scan
Hemodynamically stable patient
q Retroperitoneal assessment
Nonoperative management of solid organ injury
High specificity Cons
– Hardware, cost, radiation
– Hollow viscus injuries, diaphragm injury Laparoscopy
Role still being defined
q Good for diaphragm injury evaluation
q – Invasive
– Missed small bowel, splenic, retroperitoneal
injuries Gastric Injury
q Mostly penetrating trauma.
<1% from blunt trauma
– Including iatrogenic injury from CPR q
q NGT + aspirate for blood
Intraop evaluation includes complete visualization
of posterior wall
Most penetrating wounds treated by debridement
and primary closure in layers.
Evacuation of hematomas.
Major tissue loss may necessitate resection. Gastric Injury
q Post-op complications
– Bleeding, abscesses,
gastric fistula, empyema
gastric q Recent meal →
neutralization of gastric
acidity → increased
lower GI tract bacteria
(Bacteroides, E. coli,
Strep faecalis) →
increased Duodenal Injury
Majority due to penetrating trauma.
q Blunt injury usually secondary to steering
wheel blow to the epigastrium
q Retroperitoneal location is protective, but
also prevents early diagnosis.
q Isolated injury to the duodenum is rare
q Hyperamylasemia in 50% with blunt injury.
q Duodenal Injury
q Gastrograffin UGI or
CT w/ contrast
contrast → OR
If CT eqivocal –dilute
May see retroMay
peritoneal air on CT
DPL unreliable but
may be positive from
an associated injury
an You suspect a duodenal injury and get an
UGI w/ following result.
Which of the following are true?
2. 3. 4.
4. This patient needs a
This patient may be
This is the stacked
coin sign and
indicates a duodenal
Usually resolves in 2
weeks Duodenal Hematoma
q Slow introduction
q OR if obstruction
persists > 10 –15
q Duodenal Injury
Appropriate repair depends
on injury severity and
q 80-85% can be primarily
q Duodenal decompression
advisable if injury >6 hours
q The upper abdomen of a 42 y/o male strikes
the steering wheel during a MVA. After a
positive DPL, he undergoes an ex lap, at
which time transection of the pancreas at
the neck is found. Next step?
the Next step?
c. d. Distal pancreatectomy with oversewing
and drainage of proximal stump.
Primary repair and drainage of the
Roux-en-Y pancreaticojejunostomy to the
distal pancreas with oversewing and
drainge of the proximal stump.
Total pancreatectomy Pancreatic Injury
q Rare 10-12% of abdominal injuries, but mortality
10-25%, mostly from associated intra-abd injury
Most caused by penetrating trauma - 75%
associated with major vascular injury
Blunt trauma → compression of pancreas against
Retroperitoneal location delays diagnosis.
Role of CT improving
Pancreatic duct injury key factor in morbidity. Pancreatic Injury
Pancreatic GSW to Pancreatic Head
GSW Pancreatic Injury
q Divided into proximal or distal according to
location on the R or L of SMV
Contusions (Grade I-II) should be drained.
Distal duct injury (Grade III) → distal resection
with splenic preservation
Proximal injury (Grade IV)
– Oversewing and distal resection or
pancreaticojejunostomy in diabetic patients.
pancreaticojejunostomy q Extensive pancreatic head injuries (Grade V)
– 40% pancreatic fistula development
Simple external wide drainage Complications after Pancreatic
q High complication rate 35-40%
Most common are pancreatic fistulas & abscesses
Most fistulas close spontaneously if well drained
Somatostatin to expedite healing
Abscesses - surgical debridement & drainage
Incidence of pancreatitis 8-18%
Pseudocysts are infrequent Small Intestine Injury
q q Most common organ
injured after penetrating
– Crushing injury against
– Shearing at fixed points
– Closed loop rupture q
q Seat-belt sign should raise
DPL/CT not reliable Small Intestine Injury
Small Small Intestine Injury
q q 13% w/ perforated small
bowel have a normal CT
include free air, free
fluid w/o solid organ
injury, thickening of
small bowel wall or
mesentery Operative management
q q Bleeding initially
Penetrating injuries by
firearms should be debrided.
Small tears closed primarily.
Adjacent holes connected and
Extensive lacerations and
resection and reanasatomosis.
Explore all mesenteric
hematomas Colon Injury
q Second most frequent injured organ, usually from
Repair within 2 hours dramatically reduces
Pre-operative antibiotics important adjunct.
PE blood per rectum, stab to flanks or back
CT w/rectal contrast, XR- pneumoperitoneum
WWI primary repair led to 60% mortality.
WWII colostomy led to 35% mortality. Colon Injury
q Primary repair criteria
– q Early diagnosis (within 4-6 hours)
Absence of prolonged shock/hypotension
Absence of gross contamination
Absence of associated colonic vascular injury
Less than 6 units blood transfusion
No requirement for use of mesh for closure Extensive wounds
– Right colon → hemicolectomy +/- ileostomy
– Left colon → resection + colostomy
Left Rectal Injury
q Most from GSW
Other causes - foreign body, impalement, pelvic
fractures, and iatrogenic
Lower abdomen/buttock penetrating injury should
May be intra- or extraperitoneal
Rectal exam may reveal blood or laceration
Work-up includes anoscopy and rigid
sigmoidoscopy. Rectal Injury
q Extraperitoneal injury
– Primary closure
– Diverting colostomy
– Washout of rectal
– Wide presacral
drainage q Intraperitoneal injury
– Primary closure
– Diverting colostomy Liver Trauma
q Frequently injured in both blunt & penetrating
Control of profuse bleeding from deep lacerations
a formidable challenge.
– Simple suture, mattress sutures, packing, debridement,
resection, mesh hepatorrhaphy
resection, q Nonoperative treatment (blunt trauma)
– Stable without peritoneal signs → U/S → CT
– Low-grade liver lesions (1-3, 95% success)
– ICU monitoring Liver Trauma
Liver Liver Trauma
Liver In the event of continued bleeding a vascular
clamp can be placed around porta hepatis
If bleeding continues…
A. It is coming from the
portal vein or hepatic
B. It is coming from the
cava or hepatic veins
cava Finger Fracture Hepatotomy
q Alternative approach for
Extend laceration along
non anatomical plains to
expose and directly ligate
Low mortality 10.7%
Large defect in liver
Should only be performed
by experienced surgeons
q q q
q Used when other techniques
fail in controlling
Use in patients that are
ICU for rewarming
Re-explore 48-72 hours
Intra-abd abscesses <15%
useful adjunct Of the following hemodynamically stable patients, who is
most likely to fail non-operative management.
D. E. 8 y/o girl s/p left lateral abdominal blow playing soccer. CT
with 3cm laceration with blood around spleen and liver.
22 y/o male restrained low speed MVA with left lower rib
fractures. CT with 3cm laceration with blood around spleen
15 y/o boy tackled playing football. CT with 3 splenic
lacerations, blood around spleen, liver, and in pelvis.
21 y/o intoxicated restrained high speed MVA. CT with deep
splenic laceration, upper pole contusion, and perisplenic
25 y/o male pinned under car when it feel from its lumberjack
and landed on his upper chest. CT with deep splenic
laceration, blush of intravenous contrast by laceration, and
perisplenic Splenic Injury
Most frequently injured intra-abdominal
organ in blunt trauma.
q Splenic preservation when possible
q q q OPSI (0.6% in children, 0.3% in adults) More than 70% can be treated nonoperatively Splenic Injury
q Nonoperative criteria
– Hemodynamic stability
– Negative abdominal examination
– Absence of contrast extravasation
q Angiography/embolization an option – No other clear indications for ex lap
– No coagulopathy
– Low grade injuries (1-3) Splenic Injury
Splenic Splenic Injury
Splenic Splenic Injury
Splenic 30 year-old man ejected from automobile after head-on
collision at high speed. Sustained pelvic fracture.
Grossly positive supra-umbilical DPL. On exploration,
a pelvic hematoma and an expanding central hematoma
are noted. Next step?
Observation of both hematomas.
Exploration of both hematomas.
Exploration of central hematoma after obtaining
proximal and distal vascular control; observation of the
Observation of central hematoma, and exploration of the
pelvic hematoma after application of external fixators.
pelvic Retroperitoneal hematoma
q Zone 1
– Explore regardless of
mechanism. q Zone 2
– Explore penetrating
– Observe blunt trauma
urologic indications) q Zone 3
– Explore penetrating.
– Observe blunt. Damage Control
Abbreviated laparotomy and temporary
q Effort to blunt physiologic response to
shock and hemorrhage
q – Severe metabolic acidosis, coagulopathy, and
hypothermia ICU resuscitation
q Return to OR in 48-72 hours
q Damage Control
Damage 30 y/o woman sustained crushing injury to right
lower leg. Arrived at hospital 12 hours later. PE
reveals tense calf and closed tibia-fibula
fracture. Unable to dorsiflex foot, absent pedal
pulses. Next step?
Below knee amputation
Four compartment fasciotomy
Surgical exploration of popliteal artery
Internal fixation of tibial fracture Compartment Syndrome
Common in forearm and lower leg
secondary to defined fascial boundaries.
q Four Ps: pressure, pain, paresthesia, and
q Compartment pressure measurement
q – Critical pressure? (20-30mm Hg)
– MAP - compartment pressure < 40mm Hg Compartment Syndrome
Fasciotomy Extremity Injuries
Extremity With regard to cervical spine injury, which of
the following is/are true?
a. Jefferson fractures (C1) are usually caused
by axial load and involve blowout of the
b. Hangman’s fractures are unstable and are
best treated by operative spinal fusion.
c. Type II odontoid fractures are considered
stable. Spine Trauma
q C1 burst fractures (Jefferson’s)
– Axial loading force
– Considered stable
– Treat with rigid cervical collar q Hangman’s fracture
– Extension and distraction force
Posterior C2 elements
Traction → halo vest
Traction Odontoid Fractures
q Type I
– q Type II
– q Above base
Cervical collar or halo jacket
<5mm displacement → halo jacket
>5mm displacement → surgical tx
>5mm Type III
– Extension into vertebral body
– Halo jacket
– >5mm displacement → surgical tx
>5mm Spine Trauma
q q Strict immobilization during
– High spine injuries
– Loss of sympathetic tone
– Hypotension, bradycardia, and good
peripheral q Cervical spine films
– Must visualize all 7 vertebrae including
articulation with T1
– Lateral, AP, open-mouth odontoid Spinal Cord Injury
q q q q Preservation of remaining
Optimize perfusion and prevent
ischemic secondary injury
High-dose corticosteroids for
first 24 hours
– Restoration of anatomy, removal of
foreign bodies, and removal of
bone, disc, hematoma
bone, q Traction devices Motor Function of spinal roots
Upper Extremity Muscle Motor Examination C5 Shoulder abduction C6 Biceps Elbow flexion C7 Triceps Elbow extension C8 Flexor carpi ulnaris Wrist flexion T1 Lumbricales Finger abduction L2 Iliopsoas Hip flexion L3 Quadriceps Knee extension L4 Lower Extremity Deltoid Tibialis anterior Ankle dorsiflexion Extensor hallucis longus Great toe extension Gastrocnemius Ankle plantarflexion L5-S1
Score Functional Ability 0 No contraction of muscle 1 Palpable muscle contraction, no limb movement 2 Able to move in gravity-neutral plane 3 Able to move against gravity 4 Diminished strength 5 Normal strength ...
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- Fall '11
- Physical trauma, Penetrating trauma, abdominal trauma