Principle of abdom trauma the lect main.ppt
- 1. 01/29/25 1
- 2. Multiple Injuries Multiple Injuries The developed countries are at WAR ( Trauma war) In Uk Trauma deaths is 14500-18000/ year In Uk Trauma deaths is 14500-18000/ year In USA Ten Times 140.000-180.000/ year In USA Ten Times 140.000-180.000/ year A Third of victims are Killed on the road. A Third of victims are Killed on the road. As in wars, it is the “ As in wars, it is the “Youth Youth” which takes the ” which takes the heaviest loss. heaviest loss. 01/29/25 2
- 3. Trauma remains the most Common Cause of Trauma remains the most Common Cause of death in industrialized nations in people death in industrialized nations in people Under 35 years of age. Under 35 years of age. Overall Causalities from this Trauma war Overall Causalities from this Trauma war occupy more hospital beds and loss of more occupy more hospital beds and loss of more working days working days than cancer and cardiac than cancer and cardiac patients combined. patients combined. 01/29/25 3
- 4. INTRODUCTION INTRODUCTION Trauma is the commonest cause of death in Trauma is the commonest cause of death in young people young people. . ABDOMINAL TRAUMA STANDS THIRD ABDOMINAL TRAUMA STANDS THIRD NEXT NEXT TO HEAD INJURY AND CHEST INJURY TO HEAD INJURY AND CHEST INJURY 25% 25% of all major trauma victims require of all major trauma victims require abdominal exploration abdominal exploration. . 4
- 5. INTRODUCTION INTRODUCTION 75% 75% Of All Blunt Trauma To Abdomen Are Of All Blunt Trauma To Abdomen Are ROAD TRAFFIC ACCIDENT ROAD TRAFFIC ACCIDENT 60% OF INJURY OCCUR IN MALES (14-30) 60% OF INJURY OCCUR IN MALES (14-30) 5
- 6. TRAUMA RELATED DEATHS TRAUMA RELATED DEATHS Trauma related deaths form 3 Peaks Trauma related deaths form 3 Peaks – First Peak First Peak accounts 50% die instantly or accounts 50% die instantly or very soon. very soon. – Second Peak Second Peak accounts 30% in hours of accounts 30% in hours of injury due to severe blood loss. injury due to severe blood loss. – Third Peak Third Peak accounts 20% in days to weeks accounts 20% in days to weeks due to infection/multi organ failure. due to infection/multi organ failure. 6
- 7. The management in the first few minutes is The management in the first few minutes is crucial for the final outcome crucial for the final outcome (golden hour) (golden hour) History is Difficult because of : History is Difficult because of : -Clinical urgency. -Clinical urgency. - Absence of witness at the time of - Absence of witness at the time of accident. accident. So?? So?? General Principles in Management General Principles in Management of Multiple Injures of Multiple Injures 01/29/25 7
- 8. So So In every trauma patient In every trauma patient assume the worst assume the worst and and proceed as if : proceed as if : - Airway Airway is Compromised. is Compromised. - Neck Neck is fractured. is fractured. - Intravascular space Intravascular space is contracted. is contracted. - Stomach Stomach is full. is full. 01/29/25 8
- 9. General management Plan General management Plan = 3Rs = 3Rs 1- 1- R Resuscitate. esuscitate. 2- 2- R Review Then. eview Then. 3- 3- R Repair. epair. 01/29/25 9
- 10. (A) (A)Highest priority. Highest priority. 1- Cervical spine injuries 1- Cervical spine injuries (immobilization) (immobilization) 2- Respiratory impairment 2- Respiratory impairment (Thoracic injuries) (Thoracic injuries) 3- Cardiovascular insufficiency. 3- Cardiovascular insufficiency. -Tamponade decompression -Tamponade decompression 4-Severe external bleeding. 4-Severe external bleeding. - Bleeding arrest - Bleeding arrest Priorities Priorities 01/29/25 10
- 11. (B) High Priority : (B) High Priority : - Abdominal Injuries. - Abdominal Injuries. - Brain and Spinal cord injuries - Brain and Spinal cord injuries - severe burn (major) - severe burn (major) - - Extensive soft tissue injuries. Extensive soft tissue injuries. 01/29/25 11
- 12. (C) Low Priority : (C) Low Priority : - Lower genitourinary injuries. - Lower genitourinary injuries. -Peripheral vascular nerve and tendon -Peripheral vascular nerve and tendon injuries. injuries. - Fractures and dislocations. - Fractures and dislocations. - Facial and soft tissue injuries. - Facial and soft tissue injuries. - Tetanus prophylaxis. - Tetanus prophylaxis. 01/29/25 12
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- 14. Abdominal Injuries Abdominal Injuries The KEY to Saving Lives The KEY to Saving Lives The abdomen is the The abdomen is the “Black Box” “Black Box” I.e., it is impossible to know what specific injuries have I.e., it is impossible to know what specific injuries have occurred at initial evaluation occurred at initial evaluation The key to saving lives in abdominal trauma is The key to saving lives in abdominal trauma is NOT NOT to to make an make an accurate diagnosis, accurate diagnosis, but rather but rather to to recognize recognize that that there is an abdominal injury there is an abdominal injury
- 15. The Plan The Plan Abdominal Anatomy Abdominal Anatomy Mechanisms of Injury Mechanisms of Injury Common Pathology Common Pathology Evaluation Evaluation Management Management
- 16. Part 1: Part 1: Abdominal Anatomy Abdominal Anatomy
- 17. Upper Abdomen CT : Upper Abdomen CT :1-liver 1-liver 2-Aorta 3-Stomach 4-Spleen 5-Diaphragm 2-Aorta 3-Stomach 4-Spleen 5-Diaphragm
- 18. Lower Abdomen CT Lower Abdomen CT
- 20. Anatomical Consideration Anatomical Consideration Anatomic boundaries Anatomic boundaries – Diaphragm to pelvic brim Diaphragm to pelvic brim Abdomen can be divided in four areas Abdomen can be divided in four areas - Intra thoracic abdomen Intra thoracic abdomen - True abdomen True abdomen - Pelvic abdomen Pelvic abdomen - Retroperitoneal abdomen Retroperitoneal abdomen
- 21. Anatomical Considerations Anatomical Considerations 1-Intra thoracic area 1-Intra thoracic area (lies beneath the rib cage) (lies beneath the rib cage) - diaphragm – stomach – Liver -spleen. - diaphragm – stomach – Liver -spleen. 2-Pelvic abdomen 2-Pelvic abdomen - urinary B- urethra - rectum – small - urinary B- urethra - rectum – small intestine – uterus – tubes - ovaries. intestine – uterus – tubes - ovaries. 01/29/25 21
- 26. 3-Retroperitoneal abdomen : 3-Retroperitoneal abdomen : - Kidneys – Ureters – pancreas - great - Kidneys – Ureters – pancreas - great vessels - duodenum 2 vessels - duodenum 2nd nd & 3 & 3rd rd parts. parts. 4-True abdomen : 4-True abdomen : -Small and large intestines. -Small and large intestines. 01/29/25 26
- 31. Abdominal Organs Abdominal Organs Three types of organs Three types of organs – Solid Solid – Hollow Hollow – Vascular Vascular
- 32. 32 Solid Organs Solid Organs Liver Liver Spleen Spleen Kidney Kidney Pancreas Pancreas When solid organs are injured, they bleed heavily and cause shock
- 33. 33 Hollow Organs Hollow Organs Stomach Stomach Gall bladder Gall bladder Large, small intestines Large, small intestines Ureters, urinary bladder Ureters, urinary bladder Rupture causes content spillage, inflammation of peritoneum
- 34. 34 Major Vascular Structures Major Vascular Structures Aorta Aorta Inferior vena cava Inferior vena cava Major branches Major branches Injury can cause severe blood loss ; exsanguination (bleeding out)
- 35. Vascular Anatomy Vascular Anatomy 1. Abdominal Aorta 2. Common Iliac Artery 3. Internal Iliac 4. External Iliac 5. Superior Gluteal 6. Obturator Artery
- 36. Can you tell Can you tell What are the top 3 most commonly What are the top 3 most commonly injured organs in the abdomen? injured organs in the abdomen?
- 37. Spleen Spleen (40-55%) (40-55%) Liver Liver (35-45%) (35-45%) Small bowel Small bowel (5-10%) (5-10%)
- 38. Part 2: Part 2: Mechanisms and Mechanisms and Pathology Pathology
- 39. Prevention Strategies Prevention Strategies Reduction of morbidity and Reduction of morbidity and mortality mortality – Safety equipment Safety equipment – Prehospital education Prehospital education – Advances in hospital care Advances in hospital care – Development of trauma systems Development of trauma systems
- 40. Injury Prevention Injury Prevention 1. 1. Primary Primary: Prevent an injury from its occurrence in : Prevent an injury from its occurrence in the first place: Educational activity such as the first place: Educational activity such as anti- anti- drink-driving drink-driving campaigns, campaigns, speed limit speed limit rule rule - -Children Children should be accompanied by a parent should be accompanied by a parent 2. 2. Secondary Secondary: Attempts to lessen the consequences : Attempts to lessen the consequences of injury – of injury – making road making road & & safer car safer car, , anti-locking anti-locking brakes brakes, airbags, , airbags, helmets helmets, , seat belt seat belt 3. 3. Tertiary Tertiary: Minimize the effect of injury by : Minimize the effect of injury by health health care care by individuals & system. by individuals & system.
- 41. Injury Prevention (Contd.) Injury Prevention (Contd.) Speed is a critical factor ; a Speed is a critical factor ; a 10% increase 10% increase speed speed translate into a translate into a 40% rise in the case fatality rate. 40% rise in the case fatality rate. Use of seat belt Use of seat belt reduces the risk of death or reduces the risk of death or serious injury by serious injury by 45%. 45%. Air Bags Air Bags reduces the risk of fatal injury by 30% reduces the risk of fatal injury by 30% & deaths by 11 %. & deaths by 11 %. Children Below 12yrs should be properly Children Below 12yrs should be properly restraints in the back seat. restraints in the back seat. Motorcycle experience Motorcycle experience death rate 35 time death rate 35 time greater than car. greater than car.
- 42. Etiology Of Abdominal injuries Etiology Of Abdominal injuries Penetrating Trauma Penetrating Trauma Blunt trauma Blunt trauma Iatrogenic injuries Iatrogenic injuries
- 43. Penetrating Trauma Penetrating Trauma Stab Wound Stab Wound Gun Shot Injury Gun Shot Injury Blast Injuries Blast Injuries
- 44. Blunt Trauma Blunt Trauma Road Traffic Accidents Road Traffic Accidents Fall From Height Fall From Height Crush Injuries Crush Injuries Sport Injuries Sport Injuries Violence Violence
- 45. Iatrogenic injuries Iatrogenic injuries Endoscopic Endoscopic External Cardiac Message External Cardiac Message Peritoneal Dialysis Peritoneal Dialysis Paracentesis Paracentesis Liver Biopsy Liver Biopsy Barium Enema Barium Enema Percutaneous drainage Percutaneous drainage
- 46. A etiology & abdominal injuries A etiology & abdominal injuries Penetrating Penetrating Blunt Blunt Iatrogenic Iatrogenic - Stab wound - Stab wound -Crush injuries -Crush injuries -Laparoscopy -Laparoscopy - Gunshots - Gunshots - Blast injuries - Blast injuries -Endoscopy -Endoscopy - Seatbelt - Seatbelt syndrome syndrome -Ex. Cardiac massage -Ex. Cardiac massage -Percutaneous abscess -Percutaneous abscess drainage drainage -Peritoneal dialysis -Peritoneal dialysis -Paracentesis -Paracentesis -Percutaneous trans hepatic -Percutaneous trans hepatic canulation canulation -Liver biopsy -Liver biopsy -Barium enema -Barium enema 01/29/25 46
- 47. Examples of Abdominal Injuries Examples of Abdominal Injuries Blunt Trauma Blunt Trauma - - Aortic rupture Aortic rupture - Splenic rupture - Splenic rupture - Liver rupture or - Liver rupture or laceration laceration - Diaphragmatic tear - Diaphragmatic tear - Pelvic fracture - Pelvic fracture - Intestinal tear - Intestinal tear - Bladder rupture - Bladder rupture Penetrating Trauma Penetrating Trauma - - Laceration of blood Laceration of blood vessels vessels - Splenic rupture - Splenic rupture - Liver rupture or - Liver rupture or laceration laceration - Kidney laceration - Kidney laceration - Intestinal lacerations - Intestinal lacerations - Bladder rupture - Bladder rupture
- 48. Crush blunt abdominal trauma Crush blunt abdominal trauma 01/29/25 48
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- 52. Mechanisms of injury Mechanisms of injury The most common mechanism of blunt injury The most common mechanism of blunt injury is MVC (motor vehicle crash). is MVC (motor vehicle crash). Firearm , stabbings, are associated with Firearm , stabbings, are associated with Penetrating trauma. Penetrating trauma. Injuries result from acceleration, deceleration, Injuries result from acceleration, deceleration, or both forces. or both forces. Crushing forces compress the duodenum Or Crushing forces compress the duodenum Or the pancreas against the vertebral column. the pancreas against the vertebral column. 01/29/25 52
- 53. Mechanisms of injury Mechanisms of injury Forces applied to solid organ can rupture a surrounding capsule & injury the parenchyma as well. Structures attached by ligaments or blood vessels may be stressed at their attachment points 01/29/25 53
- 54. Mechanisms of injury Mechanisms of injury Belts if improperly positioned cause deceleration injuries to the lower abdomen , Frontal impact crashes with a bent steering wheel associated with spleen & liver injuries as well as head &chest trauma. 01/29/25 54
- 55. Seat belt Blunt Abdominal Trauma - Compressive or - Compressive or shearing forces may shearing forces may deform and rupture deform and rupture abdominal organs abdominal organs - Bruising across the - Bruising across the lower abdomen is lower abdomen is characteristic of a seat characteristic of a seat belt injury belt injury - Visible signs may - Visible signs may not reflect severity of not reflect severity of underlying injury underlying injury 01/29/25 55
- 57. One effect of Blunt Abdoninal One effect of Blunt Abdoninal Trauma Trauma Mesenteric and bowel injury from blunt abdominal trauma. Notice the bowel and mesenteric disruption. bowel mesentery
- 58. Gunshot Wounds Gunshot Wounds Handguns, Rifles, and Shotguns Handguns, Rifles, and Shotguns The degree of injury depends The degree of injury depends on on Amount of kinetic energy imparted by the bullet Amount of kinetic energy imparted by the bullet to the victim to the victim Mass of the bullet and the square of its velocity Mass of the bullet and the square of its velocity Distance Distance “crush” Bones “stretch” Tissues
- 59. General Principles of GSW General Principles of GSW Low-velocity injury (<1000ft/sec) Low-velocity injury (<1000ft/sec), damage is confined , damage is confined to missile tract. to missile tract. High-velocity injury (<2000ft/sec) High-velocity injury (<2000ft/sec), blast effect & , blast effect & cavitation occur in addition to damage by missile tract. cavitation occur in addition to damage by missile tract. 85% of ant. GSW violate the peritoneum; of these 95% 85% of ant. GSW violate the peritoneum; of these 95% require repair of intra abdominal injury. require repair of intra abdominal injury. Organs occupying the most space are more often injured Organs occupying the most space are more often injured • Small bowel(29%) Small bowel(29%) • Liver(28%) Liver(28%) • Colon(23%) Colon(23%) 59
- 60. Type I wounds Type I wounds : long range (>7 yards) , a : long range (>7 yards) , a penetration of subcutaneous tissue and deep fascia penetration of subcutaneous tissue and deep fascia only only. . Type II wounds Type II wounds : distance of (3 to 7 yards) and : distance of (3 to 7 yards) and may may create a large number of perforated structures create a large number of perforated structures. . Type III wounds Type III wounds : : occur at point-blank range (<3 occur at point-blank range (<3 yards) and yards) and involve a massive destruction of tissue involve a massive destruction of tissue *1yard=0.9meter *1yard=0.9meter
- 61. Mechanism Mechanism Gunshot wound Gunshot wound – Low velocity: <2000ft/s Low velocity: <2000ft/s (<609m/s) (<609m/s) » Damage due to direct injury to vital structures Damage due to direct injury to vital structures – High velocity: >2000ft/s High velocity: >2000ft/s (>609 m/s) (>609 m/s) » Wide debridement necessary Wide debridement necessary » Organ injury generally requires more complex Organ injury generally requires more complex techniques techniques Stab wound Stab wound – Knives are most prevalent Knives are most prevalent
- 64. Stab Wounds Stab Wounds Multiple in 20% of cases Multiple in 20% of cases Involve the chest in up to 10% of cases Involve the chest in up to 10% of cases Most stab wounds do not cause an intraperitoneal Most stab wounds do not cause an intraperitoneal injury injury The incidence varies with the The incidence varies with the direction of entry direction of entry into the peritoneal cavity into the peritoneal cavity The The liver liver, followed by the , followed by the small bowel small bowel, is the , is the organ most often damaged by stab wounds. organ most often damaged by stab wounds.
- 65. Penetrating Abdominal Penetrating Abdominal Trauma Trauma Visible wounds may Visible wounds may not reflect severity of not reflect severity of underlying injury underlying injury Significant internal Significant internal bleeding likely bleeding likely Bowel injury likely Bowel injury likely Patient may be in Patient may be in shock shock
- 67. Impalement Injuries Impalement Injuries DO NOT REMOVE DO NOT REMOVE OBJECT OR EXERT OBJECT OR EXERT ANY FORCE UPON IT! ANY FORCE UPON IT! – Severe bleeding may Severe bleeding may occur causing shock occur causing shock Check pulses distal to Check pulses distal to impaled object impaled object Immobilize the object Immobilize the object Apply bulky support Apply bulky support bandages to hold in place bandages to hold in place
- 69. Evisceration Evisceration Extrusion of abdominal contents secondary to penetrating abdominal trauma
- 71. Eviseration
- 72. Small bowel injury is the most common Small bowel injury is the most common injury resulting from ___ abdominal injury resulting from ___ abdominal trauma. trauma. penetrating penetrating blunt blunt
- 73. Small bowel injury is the most common Small bowel injury is the most common injury resulting from ___ abdominal injury resulting from ___ abdominal trauma. trauma. penetrating penetrating blunt blunt
- 74. Signs and Symptoms of Signs and Symptoms of Abdominal Injuries Abdominal Injuries Blunt Trauma Blunt Trauma - Significant - Significant mechanism mechanism - Abdominal pain - Abdominal pain - Distension - Distension - Discoloration of - Discoloration of abdomen or flank abdomen or flank - Unexplained shock - Unexplained shock Penetrating Trauma Penetrating Trauma - Visible truncal injury - Visible truncal injury including chest or including chest or abdomen abdomen - Abdominal pain - Abdominal pain - Bleeding - Bleeding - Impaled object - Impaled object - Evisceration - Evisceration - Shock - Shock
- 75. Frequency of injuries in penetrating abd. Trauma Frequency of injuries in penetrating abd. Trauma Organ Organ % % Liver Liver 37 37 Small bowel Small bowel 26 26 Stomach Stomach 19 19 Colon Colon 17 17 Major vascular Major vascular 13 13 Retroperitonel haematoma Retroperitonel haematoma 10 10 Mesentery and omentum Mesentery and omentum 10 10 Spleen Spleen 7 7 Diaphragm Diaphragm 5 5 Kidney Kidney 5 5 Pancreas Pancreas 4 4 Duodenum Duodenum 2 2 Biliary system Biliary system 1 1 Others Others 1 1 01/29/25 75
- 76. Frequency of injury in blunt abdominal trauma Frequency of injury in blunt abdominal trauma Organ Organ % % Spleen Spleen 25 25 Kidney Kidney 12 12 Intestine Intestine 15 15 Liver Liver 15 15 Retro peritoneal haematoma Retro peritoneal haematoma 13 13 Mesentery Mesentery 5 5 Pancreas Pancreas 3 3 Diaphragm Diaphragm 2 2 Urinary bladder Urinary bladder 6 6 Urethra Urethra 2 2 Vascular Vascular 2 2 01/29/25 76
- 78. Management of Abdominal Trauma Management of Abdominal Trauma General Considerations General Considerations * *Abdominal trauma is often combined with Abdominal trauma is often combined with Multiple injuries which tend to be more Multiple injuries which tend to be more obvious than the abdominal one. obvious than the abdominal one. *The management follow the same rules *The management follow the same rules RRR RRR -- R -- Resuscitation esuscitation – – R Review eview -- -- R Repair. epair. 01/29/25 78
- 79. Management of Abd. Trauma Management of Abd. Trauma Pre-hospital Care : - Little can be done for abd. injury other than general measures. - Penetrating Wounds -sterile dressing - FBs embedded, in the Trunk should Not be removed, Major bleeding may follow removal. - Evisceration is best left undisturbed *Apply sterile dressing. *Protect from further injury. 01/29/25 79
- 80. Prehospital Care Prehospital Care The goal of prehospital is to deliver the pt to The goal of prehospital is to deliver the pt to hospital for definitive care as rapidly as hospital for definitive care as rapidly as possible. possible. ‘Scoop and Run’ ‘Scoop and Run’ Maintain airway & start I V line Maintain airway & start I V line Care of spinal cord Care of spinal cord Communicate to medical control Communicate to medical control Rapid transport of patient to trauma centre Rapid transport of patient to trauma centre
- 81. Emergency Care Emergency Care I V fluids I V fluids Control external bleeding Control external bleeding Dressing of wounds Dressing of wounds Protect eviscerated organs with a sterile dressing Protect eviscerated organs with a sterile dressing Stabilize an impaled object in place Stabilize an impaled object in place Give high flow oxygen Give high flow oxygen Immobilize the patient with a fractured pelvis Immobilize the patient with a fractured pelvis Keep the patient warm Keep the patient warm Analgesics Analgesics
- 82. Clinical assessment of abdominal Clinical assessment of abdominal trauma trauma History : History : - Mechanism of trauma. Mechanism of trauma. - Direction of penetration (Knife-bullet) Direction of penetration (Knife-bullet) - Shoulder or back pain. Shoulder or back pain. - Pathological Organ disease hepatitis, diabetes, Pathological Organ disease hepatitis, diabetes, hypertensions…….. hypertensions…….. - Drug treatment (steroids……. Drug treatment (steroids……. 01/29/25 82
- 83. Examination : Examination : - Vital Signs. Vital Signs. - Examination Should be in ordinary fashion. - Examination Should be in ordinary fashion. - Penetrating Wounds delineated. Penetrating Wounds delineated. - Small abrasions and areas of ecchymosis may warn Small abrasions and areas of ecchymosis may warn sever Intra-abdominal injury. sever Intra-abdominal injury. - Abd. Wall and back inspected. - Abd. Wall and back inspected. - Abdominal distension – tenderness - guarding-rigidity - Abdominal distension – tenderness - guarding-rigidity - absent intestinal sounds - flank fullness absent intestinal sounds - flank fullness - - special signs. special signs. 01/29/25 83
- 84. Abdominal Trauma: Examination Abdominal Trauma: Examination Inspection:- Inspection:- - Abdominal distension - Abdominal distension -Movement of Abdominal wall -Movement of Abdominal wall -Record all external marks of injury -Record all external marks of injury - Record entry & exit site of bullet injury Record entry & exit site of bullet injury - Discoloration of skin Discoloration of skin
- 85. Examination Examination Laceration Laceration Abrasion Abrasion Entry/Exit wounds Entry/Exit wounds Involvement chest Involvement chest & Head injury & Head injury Seat Belt Sign Seat Belt Sign
- 86. Examination Examination Cullen’s Sign Cullen’s Sign:1918 :1918 Bluish discoloration around umbilicus Bluish discoloration around umbilicus Diffusion of blood along periumbilical Diffusion of blood along periumbilical tissues or falciform ligament tissues or falciform ligament Hemoperitoneum Hemoperitoneum Severe pancreatitis Severe pancreatitis
- 87. Examination Examination Grey-Turner’s Sign Grey-Turner’s Sign: (1877-1951) : (1877-1951) Bluish discoloration of the flanks Bluish discoloration of the flanks Retroperitoneal Hematoma Retroperitoneal Hematoma hemorrhagic pancreatitis. hemorrhagic pancreatitis. Kehr’s sign Kehr’s sign (1862-1916). (1862-1916). Referred pain, Right shoulder Referred pain, Right shoulder irritation of the diaphragm irritation of the diaphragm (Splenic injury, free air, (Splenic injury, free air, intra-abdominal bleeding) intra-abdominal bleeding)
- 88. Examination Examination Balance’s Sign Balance’s Sign Dullness on percussion of the Dullness on percussion of the left left upper quadrant ruptured spleen upper quadrant ruptured spleen Labia and Scrotum Labia and Scrotum : Pooling : Pooling of blood from abdominal and of blood from abdominal and pelvic cavities. pelvic cavities.
- 89. Examination (cont) Examination (cont) Palpation Palpation Look for tenderness/rigidity/guarding Look for tenderness/rigidity/guarding Spine tenderness Spine tenderness Pelvic compression test &compression Pelvic compression test &compression of lower chest wall of lower chest wall Per rectal examination Per rectal examination
- 90. Examination Examination Palpation: - Palpation: -Mass Mass -Tenderness -Tenderness -Signs of peritonitis -Signs of peritonitis -# Ribs -# Ribs -Chest & Pelvic compression test -Chest & Pelvic compression test
- 91. Examination (cont) Examination (cont) Percussion Percussion Look for free fluid Look for free fluid or abnormal gass or abnormal gass
- 92. Examination Examination Auscultation Auscultation : : 1. 1. Bowel sounds in the thoracic cavity Bowel sounds in the thoracic cavity (Diaphragmatic rupture) (Diaphragmatic rupture) 2. 2. Haemothorax Haemothorax
- 93. Don’t forget Don’t forget the back the back Turn the casualty over Turn the casualty over when you can do so when you can do so safely safely Visually inspect back Visually inspect back Palpate ribs, spine, Palpate ribs, spine, sacrum for tenderness sacrum for tenderness and irregularities and irregularities Dress the wound with an Dress the wound with an occlusive dressing occlusive dressing
- 94. - Abdominal girth - Abdominal girth is measured and repeated is measured and repeated - swelling - swelling or hematoma is or hematoma is marked marked with pen with pen - pelvis is Sprung - pelvis is Sprung to detect pelvic Fracture. to detect pelvic Fracture. -P.R. P.R. -Prostate (normal or floating) Prostate (normal or floating) -Abdominal or pelvic swelling. Abdominal or pelvic swelling. -Blood on the fingers. Blood on the fingers. Don’t forget Don’t forget 01/29/25 94
- 95. NB: NB: - Passage of Foley’s catheter Passage of Foley’s catheter should be should be delayed until signs of urethral injuries are delayed until signs of urethral injuries are absent. absent. - Nasogastric tube is passed Nasogastric tube is passed * Blood (In penetrating injuries) * Blood (In penetrating injuries) = Exploration. = Exploration. 01/29/25 95
- 96. Investigations Investigations Lab investigations: Lab investigations: Hematocrit estimation Hematocrit estimation Urine analysis Urine analysis Serum Amylase estimation Serum Amylase estimation another routine lab test for baseline another routine lab test for baseline
- 97. Ancillary Procedures and Investigations Ancillary Procedures and Investigations for Abd. Trauma for Abd. Trauma (1) (1)Erect Chest X-ray Erect Chest X-ray -Diaphragmatic injuries. Diaphragmatic injuries. -Rib fracture Close to liver or spleen. Rib fracture Close to liver or spleen. -Sub-phrenic gases Sub-phrenic gases rupture viscera. rupture viscera. 01/29/25 97
- 98. Erect Chest X-ray Erect Chest X-ray Tension pneumothorax Tension pneumothorax Simple pneumothorax Simple pneumothorax 01/29/25 98
- 99. Erect Chest X-ray Erect Chest X-ray Abdominal content in the chest Abdominal content in the chest Haemothorax Haemothorax 01/29/25 99
- 100. What’s wrong with this picture? What’s wrong with this picture? May only see the nasogastric tube appear to be coiled May only see the nasogastric tube appear to be coiled in the lung. in the lung. Left > right due to liver protection of the diaphragm. Left > right due to liver protection of the diaphragm. Trace the Diaphragm Outline. Where is the Diaphragm on the left? Abdominal contents Up in the chest on the left
- 101. (2)Supine abdominal X.ray (2)Supine abdominal X.ray - Splenic- hepatic and renal shadows. - Splenic- hepatic and renal shadows. - Outline of psoas muscle (Masked in - Outline of psoas muscle (Masked in retroperitoneal hematoma and splenic injury). retroperitoneal hematoma and splenic injury). - Gastric bubble shape and situation. - Gastric bubble shape and situation. - Pelvic fractures. - Pelvic fractures. - Free intra peritoneal air. - Free intra peritoneal air. 01/29/25 101
- 102. Bilateral Pubic Ramus Fractures and Bilateral Pubic Ramus Fractures and Sacroiliac Joint Disruption Sacroiliac Joint Disruption What should this injury make you worry about? What should this injury make you worry about?
- 103. (3) Abdominal Ultrasonography (3) Abdominal Ultrasonography - This focus utilization ultrasound is known as This focus utilization ultrasound is known as FAST FAST. . - Not Intended to diagnose specific injuries but to Not Intended to diagnose specific injuries but to detect free fluid intraperitoneal. detect free fluid intraperitoneal. - Rapid , Cheap , Non invasive , does not require Rapid , Cheap , Non invasive , does not require radiation& Can be repeated. radiation& Can be repeated. - Can be done parallel to resuscitation in emergency - Can be done parallel to resuscitation in emergency room. room. 01/29/25 103
- 104. N.B N.B - In unstable trauma patients In unstable trauma patients +ve FAST +ve FAST eliminates the need for further eliminates the need for further tests tests Explore. Explore. - In haemo-dynamically Stable patients - In haemo-dynamically Stable patients +ve +ve FAST FAST does NOT indicate the need for does NOT indicate the need for exploration. exploration. 01/29/25 104
- 105. Focused Assessment with Focused Assessment with Sonography for Trauma (FAST) Sonography for Trauma (FAST) 01/29/25 105
- 106. Focused Assessment with Focused Assessment with Sonography for Trauma (FAST) Sonography for Trauma (FAST) 01/29/25 106
- 107. FAST Exam FAST Exam Focused Abdominal Scanning in Trauma Focused Abdominal Scanning in Trauma 4 views: Cardiac, RUQ, LUQ, suprapubic 4 views: Cardiac, RUQ, LUQ, suprapubic Goal: evaluate for free fluid Goal: evaluate for free fluid See normal Liver and kidney Free fluid in Morrison's Pouch between liver and kidney
- 109. FAST FAST
- 110. FAST: RUQ FAST: RUQ
- 111. FAST: RUQ FAST: RUQ
- 112. FAST: RUQ FAST: RUQ
- 113. (4) Abdominal CT : (4) Abdominal CT : - Best to : Best to : -Identify and grade of solid organ injuries. Identify and grade of solid organ injuries. - Non invasive and repeatable. Non invasive and repeatable. - Low sensitivity to identify bowel and Low sensitivity to identify bowel and diaphragmatic rupture. diaphragmatic rupture. - Needs patient transfer.? Needs patient transfer.? - Used in haemo-dynamically stable patients Used in haemo-dynamically stable patients only.? only.? 01/29/25 113
- 114. CT Scan CT Scan •Gold Standard Gold Standard • Provides excellent imaging of pancreas, Provides excellent imaging of pancreas, duodenum and Genitourinary system duodenum and Genitourinary system •Standard for detection of solid organs injury. Standard for detection of solid organs injury. • Determines the source and amount of bleeding Determines the source and amount of bleeding • Can reveal other associated injuries e.g. Vertebral Can reveal other associated injuries e.g. Vertebral & Pelvic # & injury in the thoracic cavity . & Pelvic # & injury in the thoracic cavity . •High Specificity-95% High Specificity-95%
- 115. CT Scan CT Scan Contraindication: Contraindication: • Clear indication for Laparotomy Clear indication for Laparotomy • Haemodynamically Unstable Haemodynamically Unstable • Allergy to contrast media Allergy to contrast media
- 117. Abdominal CT Abdominal CT CT liver laceration CT liver laceration CT splenic injury CT splenic injury 01/29/25 117
- 118. Abdominal CT Abdominal CT CT liver laceration CT liver laceration CT splenic injury and internal CT splenic injury and internal haemorrhage haemorrhage 01/29/25 118
- 120. Splenic Injury Splenic Injury Most commonly injured organ in blunt trauma Most commonly injured organ in blunt trauma Often associated with other injuries Often associated with other injuries Left lower rib pain may be indicative Left lower rib pain may be indicative Can be managed non-operatively Can be managed non-operatively Spleen with surrounding blood Blood from spleen Tracking around liver
- 121. Splenic Lacerations Splenic Lacerations I. I. Subcapsular Hematoma <10% Surface Area Subcapsular Hematoma <10% Surface Area II. Subcapsular Hematoma 10-50% II. Subcapsular Hematoma 10-50% III. Subcapsular Hematoma >50% III. Subcapsular Hematoma >50% IV. Laceration producing devascularization of IV. Laceration producing devascularization of >25% of the spleen >25% of the spleen V. Shattered Spleen V. Shattered Spleen
- 123. Liver injury Liver injury Second most common solid organ injury Second most common solid organ injury Can be difficult to manage surgically Can be difficult to manage surgically Often associated with other abdominal injuries Often associated with other abdominal injuries Liver contusions
- 124. Liver Lacerations Liver Lacerations I. I. Subcapsular Hematoma <10% Surface Area Subcapsular Hematoma <10% Surface Area II. Subcapsular Hematoma 10-50% II. Subcapsular Hematoma 10-50% III. Subcapsular Hematoma >50% III. Subcapsular Hematoma >50% IV. Parenchymal Disruption of 25-75% IV. Parenchymal Disruption of 25-75% V. Parenchymal Disruption of >75% V. Parenchymal Disruption of >75% VI. Liver Avulsion VI. Liver Avulsion
- 126. Stellate liver laceration Stellate liver laceration
- 127. LIVER INJURY LIVER INJURY 01/29/25 127
- 129. (5) Diagnostic Laparoscopy (5) Diagnostic Laparoscopy - Most reliable method to detect peritoneal Most reliable method to detect peritoneal violation. violation. - Requires general anesthesia. - Requires general anesthesia. - High cost equipment. - High cost equipment. - Risk of tension pneumothorax in the Risk of tension pneumothorax in the presence of diaphragmatic injury. presence of diaphragmatic injury. 01/29/25 129
- 130. (6) Angiography : (6) Angiography : - Liver - Renal injuries. - Liver - Renal injuries. - Embolization. - Embolization. (7) Urgent IVU : (7) Urgent IVU : - - Important for the non- injured Kidney as Important for the non- injured Kidney as for the injured. for the injured. (8) Four Quadrant tap (8) Four Quadrant tap = Needle paracentesis : = Needle paracentesis : - - Wide bore needle and syringe. Wide bore needle and syringe. - Quick to test for intraabdominal bleeding. - Quick to test for intraabdominal bleeding. 01/29/25 130
- 131. (9) Peritoneal Lavage : (9) Peritoneal Lavage : - More Sensitive Than paracentesis. - More Sensitive Than paracentesis. - Done for those with Physical findings difficult to - Done for those with Physical findings difficult to evaluate (equivocal) evaluate (equivocal) - Unconscious trauma patients. - Unconscious trauma patients. - Unexplained shock. - Unexplained shock. - Spinal- cord injuries. - Spinal- cord injuries. 01/29/25 131
- 132. How?? How?? - Evacuate the bladder. Evacuate the bladder. - Small sub-umbilical incision under LA. Small sub-umbilical incision under LA. - Insert a peritoneal dialysis catheter. Insert a peritoneal dialysis catheter. - 500cc-1000cc Normal saline is passed 500cc-1000cc Normal saline is passed intra-peritoneally and siphoned out into a intra-peritoneally and siphoned out into a plastic bag. plastic bag. 01/29/25 132
- 135. Diagnostic Peritoneal Lavage Diagnostic Peritoneal Lavage Indications Indications Unexplained Shock Unexplained Shock Altered sensorium (Head Altered sensorium (Head injury , Drug) injury , Drug) General anesthesia for General anesthesia for extra-abdominal procedures extra-abdominal procedures Contraindications Contraindications Clear indication for Clear indication for Exploratory Laparotomy Exploratory Laparotomy Relative Relative - -Previous Expl. Laparotomy Previous Expl. Laparotomy -Pregnancy -Pregnancy -Obesity -Obesity
- 136. Positive Peritoneal lavage Positive Peritoneal lavage - Gross bloody fluid. Gross bloody fluid. - RBCs count greater than 100.000/mm3. RBCs count greater than 100.000/mm3. - WBCs greater than 500/mm3. WBCs greater than 500/mm3. - Amylase greater than 200 units%. Amylase greater than 200 units%. - Presence of bile, Faeces or bacteria. Presence of bile, Faeces or bacteria. 01/29/25 136
- 139. NOW NOW (10) - Repeated Assessment ---- so that the (10) - Repeated Assessment ---- so that the best investigation is a chair best investigation is a chair
- 140. Blunt Abdominal Trauma Blunt Abdominal Trauma CT FAST DPL Accuracy 96% 95-99% 95% Sensitivity 97% 90-92% 100% Specificity 95% 88-90% 85% Drawbacks Stable pts only Cannot evaluate retroperitoneum. Cannot identify source of fluid. 0.5% miss intestinal perforation; cannot distinguish blood v bowel contents
- 142. Initial Management Initial Management Trauma Protocol Trauma Protocol .Immobilize Cervical spine .Immobilize Cervical spine .100% oxygen .100% oxygen .Wide bore I.V line .Wide bore I.V line .Blood samples .Blood samples .Crystalloid/colloid infusion .Crystalloid/colloid infusion .Trauma series X-ray .Trauma series X-ray -Chest , cervical spine, pelvis -Chest , cervical spine, pelvis
- 143. Remember Remember In every trauma patient assume the worst and In every trauma patient assume the worst and proceed as if : proceed as if : -Airway Airway is Compromised. is Compromised. -Neck Neck is fractured. is fractured. -Intravascular space Intravascular space is contracted. is contracted. -Stomach Stomach is full. is full. 01/29/25 143
- 144. Primary survey Primary survey A- Air way management A- Air way management B-Breathing B-Breathing C-Circulation C-Circulation D-Disability D-Disability E-Exposure E-Exposure
- 145. Definitive Treatment Definitive Treatment for Abdominal Trauma for Abdominal Trauma * Conservative treatment: * Conservative treatment: - This is all that is required for the majority of - This is all that is required for the majority of cases after careful monitoring. cases after careful monitoring. * Laparotomy : * Laparotomy : - - Indicated in some but not all cases. Indicated in some but not all cases. 01/29/25 145
- 146. Conservative management by Conservative management by observation observation Hemodynamically stable patients with blunt Hemodynamically stable patients with blunt abdominal trauma with mild to moderate abdominal trauma with mild to moderate grade of solid organ injuries grade of solid organ injuries Hollow viscus injuries must have been Hollow viscus injuries must have been ruled out ruled out
- 147. Conservative Management Conservative Management Managed in ICU setting Managed in ICU setting Blood grouped & cross matched Blood grouped & cross matched Operation theater is alerted Operation theater is alerted Monitoring by Vital parameters, serial CT Monitoring by Vital parameters, serial CT Exploration done if clinical or radiological Exploration done if clinical or radiological deterioration or > 4 units blood transfusion deterioration or > 4 units blood transfusion in 24 hours in 24 hours
- 148. Operative Management Operative Management Laparotomy indicated if Laparotomy indicated if - signs of peritoneal irritation - signs of peritoneal irritation -unexplained shock -unexplained shock -evisceration of viscus -evisceration of viscus - + ve DPL + ve DPL - Deterioration during observation Deterioration during observation - Gunshot wounds Gunshot wounds - Stab wound with penetration of peritoneum? Stab wound with penetration of peritoneum?
- 149. 1- All eviscerations 1- All eviscerations (even small tag of protruding omentum). (even small tag of protruding omentum). 2- All gunshot wounds. 2- All gunshot wounds. 3- Some stab wounds with: 3- Some stab wounds with: - Significant blood loss. - Significant blood loss. - Peritonism Peritonism. . 4- Some closed abdominal injuries 4- Some closed abdominal injuries - Frank intra-peritoneal blood. - Frank intra-peritoneal blood. - Spreading Peritonitis. - Spreading Peritonitis. - urinary damage. - urinary damage. - Blood in : Stomach. Bladder or rectum. - Blood in : Stomach. Bladder or rectum. Indications of Laparotomy in abd. Trauma Indications of Laparotomy in abd. Trauma 01/29/25 149
- 150. NB: NB: Operative intervention should only be Operative intervention should only be considered after adequate hemodynamic considered after adequate hemodynamic stabilization except in stabilization except in : : 1- Horrendous bleeding outstripping all 1- Horrendous bleeding outstripping all attempts at Fluid and blood replacement attempts at Fluid and blood replacement. . 2- Evisceration with obvious Strangulation of 2- Evisceration with obvious Strangulation of the protruding viscous the protruding viscous. . 01/29/25 150
- 151. * Midline abdominal incision is: * Midline abdominal incision is: - quick. - quick. -Can be extended- (Thoraco- abdominal). -Can be extended- (Thoraco- abdominal). - Can be extended Transversely - Can be extended Transversely T shaped. T shaped. * Transverse Supraumbilical in children under 5 * Transverse Supraumbilical in children under 5 years years. . Laparotomy : How?? Laparotomy : How?? 01/29/25 151
- 152. Klinika Chirurgii Urazowej Grala
- 154. Once the abdomen is opened : Once the abdomen is opened : - Remove all blood clots. - Remove all blood clots. - Site of active bleeding is usually at the site of - Site of active bleeding is usually at the site of the recent clot the recent clot (paler – more fluid) (paler – more fluid) Control Control Massive bleeding. Massive bleeding. - pack all the 4 quadrants. - pack all the 4 quadrants. - obvious leaking hollow viscous wounds are - obvious leaking hollow viscous wounds are rapidly sutured or at least controlled first. rapidly sutured or at least controlled first. What to do?? What to do?? 01/29/25 154
- 155. Retroperitoneal hematoma Retroperitoneal hematoma Zone 1 (Central) Zone 1 (Central) – Explore regardless of Explore regardless of mechanism. mechanism. Zone 2 (Flank) Zone 2 (Flank) – Explore penetrating Explore penetrating trauma. trauma. – Observe blunt trauma Observe blunt trauma (nonexpanding, (nonexpanding, nonpulsatile, no nonpulsatile, no urologic indications) urologic indications) Zone 3 (Pelvic) Zone 3 (Pelvic) – Explore penetrating. Explore penetrating. – Observe blunt. Observe blunt.
- 156. 1- pelvic haematoma 1- pelvic haematoma associated with associated with pelvic fracture should pelvic fracture should Not Not be disturbed. be disturbed. 2- perinephric haematoma 2- perinephric haematoma (Stable-Not (Stable-Not expanding) are best left undisturbed. expanding) are best left undisturbed. Retroperitoneal haematomas : Retroperitoneal haematomas : 01/29/25 156
- 157. 3-Central haematomas that may involve 3-Central haematomas that may involve Injury to Injury to : : -Major Vessels. -Major Vessels. -pancreas. -pancreas. -Duodenum. -Duodenum. Noted Noted Minor Minor Leave. Leave. major-or-expanding major-or-expanding explore explore After Control of all injuries in the After Control of all injuries in the peritoneal cavity. peritoneal cavity. 01/29/25 157
- 158. R Retroperitoneal etroperitoneal H Haematoma aematoma G Gain acces ain access s: : D Division of gastrohepatic lig., ivision of gastrohepatic lig., left left medial visceral medial visceral rotation ( rotation (Mattox maneuver), Mattox maneuver), right right visceral rotation visceral rotation (Catell maneuver) (Catell maneuver) with Kocher with Kocher maneuver maneuver direct repair, rarely grafting direct repair, rarely grafting
- 159. R Retroperitoneal etroperitoneal H Haematoma aematoma Z I Z I - - RPH (supramesocolic) – Mattox m. RPH (supramesocolic) – Mattox m. Z II Z II - - RPH (flank) – unless pulsatile, expanding or RPH (flank) – unless pulsatile, expanding or ruptured do not explore ruptured do not explore Z III Z III - - RPH (pelvic) – as above, packing or RPH (pelvic) – as above, packing or angiographic embolisation if required angiographic embolisation if required
- 160. Klinika Chirurgii Urazowej Grala Cattel maneuver Cattel maneuver
- 161. Klinika Chirurgii Urazowej Grala Mattox maneuver Mattox maneuver
- 162. Once bleeding and contamination are Once bleeding and contamination are controlled. controlled. Thorough exploration- Thorough exploration- methodical is performed. methodical is performed. 01/29/25 162
- 163. Immediate laparotomy Immediate laparotomy Shock Shock Peritonsim Peritonsim Evisceration Evisceration
- 165. Categories of hemodynamics Categories of hemodynamics Dying patients Dying patients – Emergent laparotomy is indicated Emergent laparotomy is indicated Unstable groups Unstable groups – Emergent laparotomy may be needed , if ABCs are Emergent laparotomy may be needed , if ABCs are well performed with poor response well performed with poor response Stable groups Stable groups – Decision according to clinical presentation or trauma Decision according to clinical presentation or trauma mechanism mechanism
- 166. Summary Summary Injuries are Preventable Injuries are Preventable Trauma is a massive & growing health burden Trauma is a massive & growing health burden worldwide ,which increasingly afflicts the young & worldwide ,which increasingly afflicts the young & productive age group. productive age group. Repeated assessment is required to make the diagnosis Repeated assessment is required to make the diagnosis Ultrasonography and peritoneal aspiration are rapid Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of methods of determining or excluding the presence of Hemoperitoneum Hemoperitoneum Conservative approach in Liver & Renal Injury Conservative approach in Liver & Renal Injury Successful m/m of trauma requires integration of Successful m/m of trauma requires integration of Prehospital ,in-hospital ,& rehabilitative care. Prehospital ,in-hospital ,& rehabilitative care.
- 167. الحم ــــ لل د ــــ ه حسن على لكم شكرا استماعكم 01/29/25 167
Editor's Notes
- #140: IN the past, mandatory exploration for suspected abdominal injury resulted in unacceptably high negative and nontherapeutic laparotomy rates, which are associated with 18% and 45% morbidity rates, respectively. We have evolved to using diagnostic modalities to identify those who do not require a laparotomy. Low specificity of DPL is reason that it’s associated with 20%rate of nontherapeutic ex-lap.