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HollowViscusInjuries - Hollow Viscus Injury The Evil that...

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    Hollow Viscus Injury: The Evil that Lurks Within (the Abdomen) Sinai Hospital Dept of Surgery Trauma Conference March 23, 2005 Case: David Hernandez Algorithm: Michele Manahan Management: Dorry Segev
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    Initial Presentation Previously healthy 4 year old boy Seatbelt-restrained MVC passenger 3/2/04 Airway intact, no respiratory distress. Hemodynamically stable. Interactive. No abdominal pain. No n/v. Supraumbilical ecchymosis. Head CT, Abdo CT 3/2 morning - negative. To PICU for observation. Case Presentation
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    Initial Observation Developed fever in PICU. Abd still soft, nondistended, nontender. Tachycardic. Hypoactive bowel sounds. Repeat CT 3/2 evening – free fluid and free air. Case Presentation
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    Operative Findings Exploratory laparotomy. Soiled ascites. Fibrinous exudate on serosal surfaces of bowel. Serosal tear distal ileum, oversewn. 1 cm by 0.7 cm full thickness hole in left colon. Primary repair 4-0 vicryl. Copious irrigation. Primary closure including skin. Returned to PICU. Case Presentation
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    Postoperative ICU Course Profoundly septic. Fluid seeking. Febrile. Vasopressors for 36 hours. Significant abdominal wall erythema. Extubated POD #2. Transferred to floor. Case Presentation
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    Postoperative Course Persistent fevers. Broad spectrum abx. Bowel rest / TPN. Bilious vomiting. CT 3/8 – minimal undrainable fluid collections. Case Presentation
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    Continued Postop Course Vomiting subsided. Diet advanced and tolerated. Defervesced. Abx continued while in hospital. CT 3/12 shown – small loculated abscesses. CT 3/16 not shown – near-complete resolution. Case Presentation
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    The Saga Continues Discharged home POD #14. Well at home for several days, low grade temps. Spiked another fever 4 days after discharge. Seen in ER, tolerating diet, benign abdomen. CT – minimal undrainable collections. Discharged home from ER. Case Presentation
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    Diagnosis Penetrating abdominal trauma Blunt abdominal trauma Diagnostic Workup Indications for Laparotomy
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    Penetrating Abdominal Trauma Diagnosis Immediately to OR if: Diffuse abdominal tenderness No diffuse tenderness but hemodynamically labile without  other injuries No diffuse tenderness, hemodynamically stable, left or right  anterior thoracoabdominal injury » Laparoscopy
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    Penetrating Abdominal Trauma Diagnosis Hemodynamically stable Observe stab wounds Consider CT in gun shot  wounds and act  accordingly Hemodynamically labile DPL If positive, to OR Resuscitation
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    Blunt Abdominal Trauma Diagnosis Immediately to OR if: Diffuse abdominal tenderness
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    Blunt Abdominal Trauma Diagnosis Hemodynamically stable FAST (Focused Abdominal  Sonogram for Trauma)  AND CT Act according to findings
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