Абдоминальная травма

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.

Next step?
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. Next step?
Exploratory laparotomy
Diagnostic peritoneal lavage
Serial observation
Abdominal CT scan
Abdominal ultrasonography

Abdomen
25% of all trauma patients require ex lap.
Physical exam can be unreliable
AMS, compensated hemoperitoneum, retroperitoneal, pelvic injuries
Diagnostic tools:
Diagnostic peritoneal lavage (DPL)
Ultrasound
CT
Laparoscopy

Diagnosis
Test of choice dependent on hemodynamic stability and severity of associated injuries.
Stable blunt trauma → FAST or CT
Unstable blunt trauma → FAST or DPL
Stab wounds without peritoneal signs, evisceration, or hypotension → wound exploration or DPL.
Gun shot wounds → surgical exploration.

DPL
Standard criteria
10cc gross blood
RBC>100,000/mm2 (5% miss)
WBC>500/mm2
Amylase>175 IU/dL
Bile, bacteria, or food
Contraindications
Clear indication for ex lap
Prior abdominal surgeries
Pregnancy
Obesity
*NGT, foley

DPL
Highly sensitive to intraperitoneal blood, but low specificity → nontherapeutic explorations.
Supraumbilical if pelvic fracture present
Significant injuries may be missed
Diaphragm
Retroperitoneal hematomas
Renal, pancreatic, duodenal
Minor intestinal
Extraperitoneal bladder injuries

Focused Assessment with Sonography for Trauma (FAST)

FAST
Pros
Noninvasive
Fast
Low cost
Cons
User dependent
Obesity, gas interposition
Misses retroperitoneal/hollow viscus injury
May not detect free fluid <50-80 cc

CT Scan
Hemodynamically stable patient
Pros
Retroperitoneal assessment
Nonoperative management of solid organ injury
High specificity
Cons
Hardware, cost, radiation
Hollow viscus injuries, diaphragm injury

Laparoscopy
Role still being defined
Good for diaphragm injury evaluation
Cons
Invasive
Expensive
Missed small bowel, splenic, retroperitoneal injuries

Gastric Injury
Mostly penetrating trauma.
<1% from blunt trauma
Including iatrogenic injury from CPR
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
Post-op complications
Bleeding, abscesses, gastric fistula, empyema
Recent meal → neutralization of gastric acidity → increased lower GI tract bacteria (Bacteroides, E. coli, Strep faecalis) → increased infection

Duodenal Injury
Majority due to penetrating trauma.
Blunt injury usually secondary to steering wheel blow to the epigastrium
Retroperitoneal location is protective, but also prevents early diagnosis.
Isolated injury to the duodenum is rare
Hyperamylasemia in 50% with blunt injury.

Duodenal Injury
Gastrograffin UGI or CT w/ contrast
Extravasation of contrast → OR
If CT eqivocal –dilute barium UGI
May see retro- peritoneal air on CT
DPL unreliable but may be positive from an associated injury

You suspect a duodenal injury and get an UGI w/ following result. Which of the following are true?
This patient needs a laparotomy
This patient may be managed non operatively
This is the stacked coin sign and indicates a duodenal rupture
Usually resolves in 2 weeks

Duodenal Hematoma
NGT until peristalsis resumes.
Slow introduction of food.
OR if obstruction persists > 10 –15 days.

Duodenal Injury
Appropriate repair depends on injury severity and elapsed time
80-85% can be primarily repaired.
Duodenal decompression advisable if injury >6 hours old.

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?

Next step?
Distal pancreatectomy with oversewing and drainage of proximal stump.
Primary repair and drainage of the pancreatic duct.
Roux-en-Y pancreaticojejunostomy to the distal pancreas with oversewing and drainge of the proximal stump.
Total pancreatectomy

Pancreatic Injury
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 vertebral column
Retroperitoneal location delays diagnosis.
Elevated amylase/lipase
Role of CT improving
Pancreatic duct injury key factor in morbidity.

Pancreatic Injury

GSW to Pancreatic Head

Pancreatic Injury
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.
Extensive pancreatic head injuries (Grade V)
40% pancreatic fistula development
Simple external wide drainage

Complications after Pancreatic Trauma
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
Most common organ injured after penetrating trauma
Blunt trauma
Crushing injury against vertebral bodies
Shearing at fixed points
Closed loop rupture
Seat-belt sign should raise suspicion.
DPL/CT not reliable

Small Intestine Injury

Small Intestine Injury
13% w/ perforated small bowel have a normal CT scan
Suggestive findings include free air, free fluid w/o solid organ injury, thickening of small bowel wall or mesentery

Operative management
Bleeding initially controlled/leakage clamped
Penetrating injuries by firearms should be debrided.
Small tears closed primarily.
Adjacent holes connected and closed transversely.
Extensive lacerations and devascularization require resection and reanasatomosis.
Explore all mesenteric hematomas

Colon Injury
Second most frequent injured organ, usually from penetrating trauma
Repair within 2 hours dramatically reduces infectious complications.
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
Primary repair criteria
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

Rectal Injury
Most from GSW
Other causes - foreign body, impalement, pelvic fractures, and iatrogenic
Lower abdomen/buttock penetrating injury should raise suspicion.
May be intra- or extraperitoneal
Rectal exam may reveal blood or laceration
Work-up includes anoscopy and rigid sigmoidoscopy.

Rectal Injury
Extraperitoneal injury
Primary closure
Diverting colostomy
Washout of rectal stump
Wide presacral drainage
Intraperitoneal injury
Primary closure
Diverting colostomy

Liver Trauma
Frequently injured in both blunt & penetrating trauma.
Control of profuse bleeding from deep lacerations a formidable challenge.
Simple suture, mattress sutures, packing, debridement, resection, mesh hepatorrhaphy
Nonoperative treatment (blunt trauma)
Stable without peritoneal signs → U/S → CT
Low-grade liver lesions (1-3, 95% success)
ICU monitoring

Liver Trauma

Liver Trauma

In the event of continued bleeding a vascular clamp can be placed around porta hepatis
Pringle Maneuver
If bleeding continues…
It is coming from the portal vein or hepatic artery
OR
B. It is coming from the retrohepatic vena cava or hepatic veins

Finger Fracture Hepatotomy
Alternative approach for deep lacerations
Extend laceration along non anatomical plains to expose and directly ligate bleeding vessels
Low mortality 10.7%
Large defect in liver parenchyma
Should only be performed by experienced surgeons

Packing
Used when other techniques fail in controlling hemorrhage
Use in patients that are hypothermic, acidotic, coagulopathic
ICU for rewarming
Re-explore 48-72 hours
Intra-abd abscesses <15%
Arteriography/embolization useful adjunct

Of the following hemodynamically stable patients, who is most likely to fail non-operative management.
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 and liver.
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 blood.
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 blood.

Splenic Injury
Most frequently injured intra-abdominal organ in blunt trauma.
Splenic preservation when possible
OPSI (0.6% in children, 0.3% in adults)
More than 70% can be treated non-operatively

Splenic Injury
Nonoperative criteria
Hemodynamic stability
Negative abdominal examination
Absence of contrast extravasation
Angiography/embolization an option
No other clear indications for ex lap
No coagulopathy
Low grade injuries (1-3)

Splenic Injury

Splenic Injury

Splenic Injury

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 pelvic hematoma.
Observation of central hematoma, and exploration of the pelvic hematoma after application of external fixators.

Retroperitoneal hematoma
Zone 1
Explore regardless of mechanism.
Zone 2
Explore penetrating trauma.
Observe blunt trauma (nonexpanding, nonpulsatile, no urologic indications)
Zone 3
Explore penetrating.
Observe blunt.

Damage Control
Abbreviated laparotomy and temporary packing
Effort to blunt physiologic response to shock and hemorrhage
Severe metabolic acidosis, coagulopathy, and hypothermia
ICU resuscitation
Return to OR in 48-72 hours

Damage Control

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?
Angiography
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.
Four Ps: pressure, pain, paresthesia, and intact pulses
Compartment pressure measurement
Critical pressure? (20-30mm Hg)
MAP - compartment pressure < 40mm Hg

Compartment Syndrome

Fasciotomy

Extremity Injuries

With regard to cervical spine injury, which of the following is/are true?
Jefferson fractures (C1) are usually caused by axial load and involve blowout of the ring.
Hangman’s fractures are unstable and are best treated by operative spinal fusion.
Type II odontoid fractures are considered stable.

Spine Trauma
C1 burst fractures (Jefferson’s)
Axial loading force
Considered stable
Treat with rigid cervical collar
Hangman’s fracture
Extension and distraction force
Posterior C2 elements
Unstable fracture
Traction → halo vest

Odontoid Fractures
Type I
Above base
Stable
Cervical collar or halo jacket
Type II
At base
Usually unstable
<5mm displacement → halo jacket
>5mm displacement → surgical tx
Type III
Extension into vertebral body
Halo jacket
>5mm displacement → surgical tx

Spine Trauma
Strict immobilization during ABCDEs
Neurogenic shock
High spine injuries
Loss of sympathetic tone
Hypotension, bradycardia, and good peripheral perfusion
Cervical spine films
Must visualize all 7 vertebrae including articulation with T1
Lateral, AP, open-mouth odontoid

Spinal Cord Injury
Preservation of remaining function
Optimize perfusion and prevent ischemic secondary injury
High-dose corticosteroids for first 24 hours
Surgical therapy
Restoration of anatomy, removal of foreign bodies, and removal of bone, disc, hematoma
Traction devices