Abdominal Truama

ABDOMINAL INJURY (ADD?)

causes main points physical examintion and signs organ injuries classification (4) Asessment and investigations and other investigation Process flowchart all about FAST Management options Indications for lap Pelvic injury management Where is bleeding and how to stop it Bladder rupture Abdominal compartment syndrome diaphragm rupture points small intestine points duodenal injury and x ray Liver approach delayed vs negative lap -----------------------------

Common •Could be due to –Penetrating trauma –Blunt trauma •Could be missed initially

Physical Examination

Serial physical examination has besr sensitiviy. Primary objective of physical examination is to rapidly indentify the patients who needs laparotomy and then to detect peritonitis

Pulse, blood volume, capillary refill, urine output, hypovolemia, abdominal signs

Organs which could be damaged (peritoneal or retroperitoneal or diaphhragm)

Solid organs (FAST?)

Liver Spleen Kidneys

Bleeding!

Hollow viscus (DPL?)

Large Bowel Small Bowel Bladder

Rupture -> contamination!

Diaphragm

Pelvic Injury

Strong bony structure

Tightly packed organs •Rich blood supply •Large venous network

Assessment

Primary survey (ABCDE)

Secondary survey •Adjunct investigations -Plain X Ray •Chest •Pelvis •Cervical spine Lateral -FAST

Investigations

Plain X Ray Abdomen -usually useless -value in identifying retained metal pieces •Plain X Ray Chest -may give some clues •Ultrasound Abdomen FAST •DPL (Diagnostic Peritoneal Lavarge •Contrast CT Abdomen

Urethro-cystography

IVU

Angiography

FAST

Detects blood in 4 places 4Ps –Pelvic –Pericardium –Perihepatic –Perisplenic •Extended FAST Pleura”

How much fluid can FAST detect? 250cc in total 100cc in Morrison's pouch

Beware of contrast allergies in CT scan. Other contraindications are exploratory laparotomy, haemodynamically unstable.

Peritonitis is contraindication to DPL. Perforation is risk.

All retroperitoneal haemotomas has to be explored

Haemodynamically stable vs hemodynamically unstable

Management options

Conservative management (Non operative management of solid organs) •Packing

Surgery

Liver –Repair •Kidney –Partial Nephrectomy •Spleen –Repair –Spleenectomy •Bowel –Repair –Resection and anastomosis –Stomas (Hartmann’s procudure)

Bladder –Repair

Indications for laparotomy

Stab injury, •Wait and see •Explore Bowel out side Peritonitis Free gas under the diaphragm Gunshot injury Blunt injuries

Pelvic Injury Management

Pelvic girdle •Fixation of pelvis external / internal •Bleeding »retroperitoneal packing »Blood and blood products »Angiembolistaion

Questions?

Q1 How do you differentiate intra abdominal bleeding from peritonitis due to bowel perforation?

Q2 50% of the patients with abdominal injuries who is bleeding inside will not have clinical signs at the time of admission

Points

Diaphragm - injuries are possible in thoracoabdominal region. weakest point is Lf. posterolateral. rupture with herniation is diagnosed by CXR or CT. without herniation is difficult to diagnose but thoracoscopy or laparoscopy is diagnostic

Small intestine most commonly injured in penetrating trauma. perforation from blunt injury is most common in ligament of treitz, ileocaecal valve, midjejunumor in areas of adhesions. diagnosis is clinical. treatment is operative

duodenal injury - second portion is most commonlu injured. retroperitoneal air in abdominal xray.

Liver is most commonly injured intraabdominal organ. CT is sensitive and specific. haemodynamically stable + absence of peritoneal signs + lack of need for continual transfusion = non-operative management

A negative laparotomy does not increase the complication rate but a delayed laparotomy does

MARROW

Abdominal Truama

Prep ladder