Abdominal trauma Assessment of abdominal trauma

Assessment of patients with abdominal trauma can be difficult due to o Altered sensorium (head injury, alcohol) o Altered sensation (spinal cord injury) o Injury to adjacent structures (pelvis, chest) Pattern of injury will be different between penetrating and blunt trauma

Indications for laparotomy

Unexplained shoc !igid silent abdomen "visceration !adiological evidence of intraperitoneal gas !adiological evidence of ruptured diaphragm #unshot wounds Positive result on diagnostic peritoneal lavage

Imaging

"ither $% or ultrasound can be used for the assessment of abdominal trauma $% scanning is preferred method but re&uires patient to be cardiovascularly stable Ultrasound has high specificity but low sensitivity for the detection of' o (ree fluid o )isceral damage

FAST

(ocused assessment for the sonographic assessment of trauma Is the use of ultrasound to rapidly assess for intraperitoneal fluid Probe is placed on the' o !ight upper &uadrant o *eft upper &uadrant o +uprapubic region (luid in subphrenic, subhepatic spaces or Pouch of ,ouglas in hypotensive patient $onfirms li ely need for emergency laparotomy

Peritoneal lavage Indications

"&uivocal clinical examination ,ifficulty in assessing patient Persistent hypotension despite ade&uate resuscitation -ultiple injuries +tab wounds where the peritoneum has been breached

Method

"nsure that a catheter and nasogastric tube are in.situ Under *A ma e vertical sub.umbilical incision and divide linea alba Incise peritoneum and insert peritoneal dialysis catheter Aspirate any free blood or gastric content If no blood seen . infuse /litre of normal saline an allow 0 min1 to e&uilibrate Place drainage bag on floor and allow to drain +end 23 ml to laboratory for measurement of !4$, 5$$ and microbiological examination

Positive result

!ed cell count 6 /33,333 7 mm0 5hite cell count 6 833 7 mm0 Presence of bile, bacteria or faecal material

Damage Control Surgery

(ollowing multiple trauma poor outcome is seen in those with o 9ypothermia o $oagulopathy o +evere acidosis Prolonged surgery can exacerbate these factors As a result the concept of :damage control: surgery has been developed

Initial operation

"arly management of major abdominal trauma surgery should aim to' o $ontrol haemorrhage with ligation of vessels and pac ing o !emove dead tissue o $ontrol contamination with clamps and stapling devices o *avage the abdominal cavity o $lose the abdomen without tension A plastic sheet or :4ogata bag: may be useful

Picture provided by -r1 ; $ $ampbell, ,erriford 9ospital Plymouth Intensive care unit

"arly surgery should be followed by a period of stabilisation on the intensive care unit ,uring this period the following should be addressed o !ewarming o )entilation o !estoration of perfusion o $orrection of deranged biochemistry o $ommence enteral or parenteral nutrition

'Second loo laparotomy'

Planned re.laparotomy at 2< . <= hours allows' o !emoval of pac s o !emoval of dead tissue o ,efinitive treatment of injuries o !estoration of intestinal continuity o $losure of musculofacial layers of abdominal wall %his approach has been shown to be associated with a reduced mortality

!astrointestinal in"ury

+mall bowel perforations can invariably be primarily closed %he management of colonic perforations is more controversial Used to common practice to excise damaged segment Proximal stoma was then fashioned Perforation could also be exteriorised as a stoma Increasingly recognised that primary repair of colonic injuries is safe >ow recommended method, especially in the absence of significant contamination

#ibliography 4roo es A ;, !owlands 4 ;1 4lunt abdominal injuries1 Brit Med Bull /???@ 88' =<<.=881 $urran % ;, 4orAotta A P1 $omplications of primary repair of colon injuries' literature review of 2,?B< cases1 Am J Surg /???@ /CC' <2.<C1 9oey 4 A, +chwab $ 51 ,amage control surgery1 Scand J Surg 2332@ ?/' ?2. /30 >elson !, +inger -1 Primary repair for penetrating colon injuries1 Cochrane Database Syst Rev 2332@ $,3322<C1 Dffner P ;, ,e +ouAa A *, -oore " " et al1 Avoidance of abdominal compartment syndrome in damage control laparotomy after trauma1 Arch Surg 233/@ /0B@ BCB. =/1 Par s ! 5, $hrysos ", ,iamond %1 -anagement of liver trauma1 Br J Surg /???' =B' //2/.//081 +tengel ,, 4auwens ;, +ehouli ; et al. +ystemic review and meta.analysis of emergency ultrasonography for blunt abdominal trauma1 Br J Surg 233/@ ==' ?3/. ?/21

Alameda $ounty -edical $enter $ 9ighland #eneral 9ospital Trauma Service Abdominal +tab 5ound "valuation

%hese guidelines apply only to those patients stabbed in the anterior abdomen (see anatomic boundaries in box below), who meet all three of the following criteria' /1 hemodynamically normal (i1e11 are not hypotensive, tachycardic or diaphoretic) 21 have no evidence of peritonitis 01 have no bowel or omental evisceration through the wound %he presence of any one or more of the above mandates immediate abdominal e%ploration . without delay for further investigative maneuvers or x.rays1

#oundaries of the anterior abdominal &all' 1. Superior: costal margins . !ateral: mid axillary line ". #n$erior: inguinal ligaments

I( )ocal *ound +%ploration' In stable patients, a stab wound within the boundaries of the anterior abdominal wall (see above) will first be examined for evidence of violation of the anterior abdominal fascia1 %his procedure is performed under sterile conditions (gown7glove7mas , prepping and draping), using ade&uate lighting, local anesthesia (/E lidocaine F epi) and instrumentation to extend the margins of the stab wound so as to visually and digitally explore its depth1 $otton.tipped applicators (GH.tipsG) are not to be used to probe the wound1 A( If the local wound exploration demonstrates no fascial violation, the wound is irrigated copiously and closed, and the patient may be discharged from the emergency department1 Prophylactic antibiotics are not indicated1 #( If the local wound exploration demonstrates violation of the anterior abdominal wall fascia, it should be assumed that the nife entered the peritoneal cavity1 %he wound is closed in layers after ade&uate irrigation1 %he patient will then undergo diagnostic peritoneal lavage (,P*) to determine indications for exploration (see 21 below)1 +hould there be strong contraindications to ,P* (multiple prior abdominal

operations, ascites, third trimester pregnancy, refusal of procedure by patient), the patient will be observed for a period of no less than <= hours1 Immediate exploration is also an acceptable alternative, after discussion with the patient and the attending trauma surgeon1 II( Diagnostic Peritoneal )avage' Any of the following G(F) ,P* resultsG mandates abdominal exploration' A( gross blood 6 /3 ml or any feces or any bile on initial paracentesis #( !4$ count 6 83,333 !4$ 7 mm0 C( 54$ count 6 833 7 mm0 D( 4acteria, food or vegetable particles on gram stain 7 microscopic exam Patients whose ,P* results are negative will be admitted for a minimum of 2< hours1 ,uring this period of observation they will undergo monitoring of vital signs, fre&uent abdominal examinations (& 2 hr x /2hrs, then & < hr) and repeat $4$ at /2 and 2< hours1 %hey will be fed ad lib1 Prompt abdominal exploration will be indicated for any patient developing peritoneal irritation, unexplained fever, leu ocytosis or hemodynamic instability1 Prophylactic antibiotics are not indicated during the observation period1 Analgesia will consist of intramuscular >+AI,s while >PD, followed by oral agents once oral inta e is tolerated1 If none of the abnormalities above are noted after the 2< hour period of observation, the patient may be discharged home under the care of a responsible adult1 (ollow.up to the %rauma +urgery $linic should be scheduled for within one wee 1 ,eferences /1 >agy I, !oberts !, ;oseph I, An #, 4arrett ;1 "visceration after abdominal stab wounds' is laparotomy re&uiredJ J %rauma /??? Dct@<C(<)'B22.<@ discussion B2<.B 21 Kantut *(, Ivatury !!, +mith !+, et al1 ,iagnostic and therapeutic laparoscopy for penetrating abdominal trauma' a multicenter experience1 J %rauma, /??C -ay, <2(8) =28.?1 01 (eliciano ,), 4itondo $#, +teed #, et al1 833 open taps or lavages in patients with abdominal stab wounds1 Am. J Surgery /<='CC2, /?=< home . protocols & guidelines administrative . cases . images . lin's