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general surgery > 47-48 Abdominal Trauma Blunt and Penetrating > Flashcards

47-48 Abdominal Trauma Blunt and Penetrating Flashcards

1
Q

What is the main cause of ABDOMINAL Blunt trauma

A
  1. motor vehicle & motorcycle accidents- >rapid decellaration injuries causing shearing of vessels nerves and contusion of solid organs
  2. falls,
  3. assaults,
  4. struck pedestrians
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2
Q

causes of ABDOMINAL penetrating trauma

A

according to the book

  1. gunshot wounds
    • mech = Medium-velocity or high-velocity injuries
      • Damage also caused to structures adjacent to the path of the bullet
      • Dense organs (e.g., liver, spleen) undergo more damage because they absorb more energy, resulting in greater injury.
  2. stab wounds by sharp, impaling object (e.g., knife, ice pick, broken bottle)
    • mech = Low-velocity injuries
    • Hemorrhage and infection are the most significant mechanisms responsible for morbidity and mortality.
  3. smaller number of shotgun wounds.
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3
Q

2 ways of CLASSIFICATION of ABDOMINAL TRAUMA

A

A. According to the integrity of skin and parietal peritoneum

  1. Open – skin and skin structures are damaged.
      • penetrating – parietal peritoneum is damaged.
    • non penetrating – parietal peritoneum is safe.
  2. Blunt/closed - skin and skin structures are not damaged.

B. According to the integrity of abdominal organs and structures

    • with injuries of hollow viscera
    • with injuries of parenchymatous organs.
    • both
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4
Q

Clinical signs and symptoms in abdominal blunt trauma

perforated hollow viscera: (signs of peritonitis)

liver hematoma

A
  1. Positive sign of peritoneal irritation (Blumberg)
  2. Positive sign of muscle rigidity
  3. Presence of defense of abdominal muscles (Guarding
  4. PAIN/ DISTENSION OF ABDOMEN
    * liver hematoma
    • Ecchymoses over the right chest
    • Kehr’s sign = Referred pain in the right shoulder when laying down due to diaphragmatic irritation stim the phrenic nerve. ussually secondary / assoc w/ splenic rupture https://www.youtube.com/watch?v=FskVBTZ86PY
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5
Q

Clinical signs and symptoms of acute abdominal hemorrhage

THOPP

A
  1. Tachycardia – pulse rate over 100/min.
  2. Hypotension – systolic blood pressure under 100 mm/Hg.
  3. Oliguria/Anuria – urine outflow under 40 ml/our.
  4. Pale face
  5. Pulse on a.radialis – filiformis. (thready pulse)
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6
Q

BLunt trauma dg algorithm

what is used for stable pts

first choice for unstable

indicatios of DPL

A

BLunt trauma approach/ diagnostics

  • Primary survey to asses pt status
    • pre hospital trauma care with Advanced Trauma Life Support
      • ABCDE
      • Resusciation if needed
        • infusion, CPR etc
  • Imaging to asses LOCATION and EXTENT of abdominal injury
    1. FAST exam for hemoperitoneum I/D is first choice in stable pt
      • replaced DPL as t’s non invasive
      • May be inneficative
    2. CT - stable pt’s only
      • detects retroperitoneal hematomas and free fluid in abdomen
      • if fast is inconclusive
    3. X-ray is less effective than both Fast and CT
      • used to detect fractures
    4. Diagnosic Peritoneal Lavage for hemodynamically unstable patients if FAST is inconclusive
      • most sensitive but also most invasive
      • fecal matter or significant blood are detected (positive test) → emergent laparotomy is indicated
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7
Q

Penetrating trauma algorithm

A
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8
Q

COnservative management of blunt trauma

A

depends on type of location and type/ extent of injury

general:

Close monitoring of vital signs and serial examinations

Angiography and embolization (e.g., control bleeds, manage low retroperitoneal hematomas)

specific

Management of pancreas injury: percutaneous drainage (with culture) and debridement to prevent complications (pseudocysts, abscess)

Management of duodenal injury: nasogastric suction and parenteral nutrition to allow healing; if patients remain unstable, laparotomy may be indicated.

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9
Q

Indications for Laparotomy

A
  1. Hemodynamic instability
  2. Intra-abdominal bleeding detected on imaging
  3. Signs of peritonitis (guarding, rebound tenderness/distension, nausea/vom)
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10
Q

how is emergency laparotomy performed

A
  1. Patients who require laparotomy should undergo a systematic exploration so that all areas of the abdomen are assessed and injuries are not missed.
  2. Abdomen is opened from the xiphoid process to pubic symphysis to provide adequate exposure of all abdominal structures.
  3. falciform ligament is divided, separating the liver from the abdominal wall to improve retraction and perihepatic packing.
  4. Using a hand-held retractor, blood is quickly evacuated from all four quadrants of the abdomen and laparotomy sponges are placed to provide temporary hemostasis.
  5. Entire GI tract is carefully evaluated, from the GEJ to the rectum at the peritoneal reflection. This includes entering the lesser sac to evaluate the 1.posterior stomach and the 2.pancreas.
  6. Areas stained with blood that are of concern for injury should be explored further with careful dissection.
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11
Q

SPecific types of abdominal injury

A
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12
Q

most common types of injuries in Abdominal trauma

A

Most common: splenic rupture and liver injury (e.g., hematoma, laceration)

Severe bleeding

Pancreatic contusion, laceration, or rupture (through d_irect epigastric impact, e.g., handlebar injury)_

Diaphragmatic rupture

Traumatic injuries of the kidney and bladder

Duodenal damage and hematoma: common injury in children who suffer blunt abdominal trauma

Pelvic fracture

Abdominal compartment syndrome

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13
Q

blunt traumas to the Liver from novakov book

  • cause
  • types of injury
  • treatment
    *
A
  • MC organ damaged in BLUNT abdominal truama trauma caused by RTA
    • PENETRATING wounds to the RIght ThoracoAbdominal area (nipples) if diaphragm is penetrated risk liver injury too
  • mech = SHEARING & COMPRESSION that directly damage paranchyma and ligamentous attatchments
  • specific pathology = haematomas
      • small - spontaneous resoslution
      • large RetroP hematomas from ligament detatchment of 1+ hepatic veins
  • clinical features
    • Intrabdominal hemmorhahge causes Peritoneal irriataion ( guarding, tenderness, rigidity
    • undet_ected hematomas_ -present as
      • Jaundice & billiary colic
      • bleeding into billary tree causes Haemobillia (mixture of blood in bile or to blood in the biliary tract)

TX- Large haematomas require ligation of bleeding vessels

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14
Q

spleen

which is preffered splenorrhaphy or Splenectomy

A

SPLENECTOMY in every case is advised by DR novakov at least as the goal is to save the pt life

Splennorhapphy is commonly considered in children? to preserve spleneic tissue

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15
Q

Abdominal trauma to the Stomach penetrating)

assoc injuries

type of trauma

mech

mc specific pathologies and why it’s dangerous (I F.. u dont like) to the stomach)

clinical features

-sx on nasogastric aspirate

A
  • mc stomach trauma is d/2 penetrating trauma causing full thickness perforations resulting in the spillage of gastric contents
    • blunt is rare
  • mech =
    • Acute increase in INtraluminal pressure from external forces causing the gastric wall to burst. this leads to the specific pathologies.
      • the high energy nature causes assoc injuries to liver, spleen and pancreas
  • specific patholgy
    • Intramural hematomas,
    • full thickness perforations
  • clinical features- generally non specific
    • P.E during spillage of gastric contents shows peritoneal irritation
  • Bloody nasogastric aspirate - ALARM BELLS
  • x-ray- free air in abdomen
  • TX
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16
Q

MC side effect of gastrointestinal surgery

17
Q

abdominal trauma to the duodenum

type of trauma

age group commonly affected by blunt trauma

sx

complications

which associated pathology req surgical eploration

tx

A
  • Rarely is the DUodenum injured but traumas are of the penetrating type after a GUNSHOT
  • blunt trauma to duodenum is mc in children e,g handle bar stirke to abdomem. they usually present w/ complications of GOO or peritonitis

specific pathology

  • Duodenal heamatomas->GOO
  • Full thickness perforation->PERITONITIS

clinical features

  • may be no clinical signs other than sx of complications
  • -GOO-
    • sx =>gastroeso reflux, early satiety->weight loss, abdominal pain, vomiting,
    • signs=> abdominal distention and a succussion splash on ausc
  • -peritonitis
      • Distension, Guarding, Tenderness,rigidity

dg

  • mainstay of dg of duodenal injury = CT
    • shows thickened duodenal wall or fluid outside the bowel lumen

TX - treat each pathology sep- next FC

18
Q

what is GOO

A

Gastric outlet obstruction: Any disease that mechanically impedes the normal gastric emptying.

  • There is obstruction of the channel of the pylorus which the stomach empties through and duodenum ​which the stomach empties into . The cause of the obstruction may be a benign or malignant disease.
  • The most common malignancy that produces gastric outflow obstruction is pancreatic cancer.
  • The benign causes of gastric outflow obstruction
    • in adults, include pyloric ulcer and gastric polyps
    • in children, pyloric stenosis! and congenital duodenal webs
    • in all age ranges ingestion of caustic substances.
19
Q

what is Succussion splash

A

also known as a gastric splash, is a sloshing sound heard through the stethoscope during sudden movement of the patient on abdominal auscultation. It reflects the presence of gas and fluid in an obstructed organ, as in gastric outlet obstruction

20
Q

TX of duodenal traumas

hematomas

transection

A

1- duodenal hematomas

  • small duodenal hematomas dont need rx
  • hematomas large enough to cause GOO are rxed for 7 days w/
  • parenteral nutrition and gatric decompression w/ contrast
  • after 2 weeks of bowel rest any remaining obstruction requires Exploration to observe associated Pancreatic injury

2- Full thickness duodenal injury tx

  • exposure w/ KOCHER maneuver
  • single or double layer repair
  • short duodenal transectionsw/o ampulla involvement - primary anasomosis
  • large transections - bypass
    • protect the duodennal repair from gastric contents pyloric exclusion and Gastroenterostomy
21
Q

what is kochers maneouver

A

dissection of the lateral peritoneal attachments of the duodenum to allow inspection of the retroperitoneal structures such as the duodenum, pancreas

22
Q

abdomina trauma to the Pancrea

A

rare, and usualy assoc w/ blunt trauma to duodenum

type of injury

  • penetrating injury
  • blunt
    • mech energy transmission to the RP e.g. seatbelt / steering wheel
    • high risk d/2 caustic properties of pancreatic enzymes and complications leading to systemic inflammation aka SIRS

specific pathology

  • contusion
  • complete transection with ductal disruption

dg

  • (just like duodenum) RP location makes Physical exam of pancreas inssuficient
  • no one single method of dg suff
  • abdom CT w/ I/V contrast
  • amylase levels
  • Endoscopic Retrograde Cholangio Pancreatography
  • Magnetic RCP

TX- usually surgical -

  • wide kocher maneouver to determine size, type and degree of injury. especially important to check for ductal injury (wirsung & accesory)
  • injury to the left of Superior mesenteric vessels require Pancreatectomy
  • Damage to pancreatic head w/ duodenal injury requires a Whipple procedure/ Pancreatoduodenectomy
  • SIRS is the most deadly complication as it can lead to MODS
    • manage by the Diversion of causitc pancreatic enzymes
23
Q

what is the whipple procedure AKA PANCREATODUODENECTOMY

A

2 parts

1)Removal of the

  • Gall bladder & cystic duct
  • Pancreatic HEAD w/ part of the Common bile duct,
  • Duodenum
    • classic= removal of lower half of stomach
    • Pylorus preserving - keeps the pylorus intact to (prevent dumping)
  • Superior mesenteric artery and veins- if tumor/ damage is present

2)subsequent 3 part anastomoses of

  • Pancreaus to Jejunin = PancreatoJejunostomy
  • bile duct to the jejunum = CholedocoJejunstomy
  • Stomach to Jejunum - GastroJejunostomy

https://www.youtube.com/watch?v=4Zxvm3MSb8k

https://www.youtube.com/watch?v=COr8rTnRwdE

24
Q

basic pancreatic anatomy and physio refresh

25
Q

What is the 4 criteria for SIRS and how does pancreatitis lead to it

good sirs:

1) Thank
2) The
3) Heavenly Father
4) Beg 4 Long Life

A

Four SIRS criteria https://www.youtube.com/watch?v=gAUvUZflLBc&list=PLwp4F9YlR_ss46Ag83UpQKPXsA0A36yNZ&index=5

  1. tachycardia (heart rate >90 beats/min),
  2. tachypnea (respiratory rate >20 breaths/min),
  3. fever or hypothermia (temperature >38 or <36 °C),
  4. leukocytosis, white blood cells >12,000/mm3, leukopenia (<4,000/mm3 , or bandemia ≥10%).
    • ​​excess or increased levels of band cells (immature white blood cells) released by the bone marrow into the blood

Trauma to the pancreas especially ductal system releases caustic enzymes (amylases, lipases, proteases) causing brkdown of body tissue and creating a massive inflammatory response

26
Q

abdominal trauma to the small intestines

A

Mc organ injured during PENETRATING trauma is the small bowel

Mech

  • Penetrating
  • blunt trauma is rare but decelleration can lead to intestinal rupture and shearing of the Mesenteric vessels leading to Devascularizaiton of the intestine

DG

  • injuries are usually i/d during la[arotomy

SX

  • peirtonial irritation suggests perforation

TX- of small intestinal injurues

nonabsorbalbe sutures to reinforce serosal tears

debridement and repair w/ 1-2 layers for perforation

resecction of multiple close range injuries

resection of injuries covering over 50% of bowel

Anastomosis after resection

27
Q

abdominal trauma to the Large intestine

what determines the treatment

when is colocolostomy anastomoses not performed

how do shearing forces of blunt trauma affect the lare bowel

A
  • Just like all the other Hollow viscera are susceptible to Penetrating Injuries
    • the amaount of eergy determines te degree of wall destruction
    • RP segments (Ascending & Descending) can be obscured
  • Blunt causes are similar to small bowel except shearing forces heare cause a seperation of serosa muscularis

DG = like other hollow organs Laparotomy provides diagnosis of injuries

Tx-of L.I trauma depends on 3

AMOUNT(of wall seperation )

  • if under 50% can be repaired w/ one/ two layers
  • If over 50% resection is indicated

LOCATION of WALL INJURY
Distal ijuries req resection and Colocolostomy anastomosis

PATIENT STABILITY

  • Anastomosis is C.i in shock
    • instead after resection a simple Colostomy is indicated
28
Q

Rectal injuries

A

Penetrating is mc especially in pelvic fracture that can Lacerates the reacal tissue

blunt is less than 1% same as the colon

Specific pathology

  • -rectal hematoma
  • -laceration
  • -Perforation - septic risk - > imm operation

dg

  • blood during DRE requires additional exam
  • w/ stable pts= RIGID Proctosigmoidoscopy
  • unstable pts require laparotomy
  • TX of rectal injury
  • during healing to prevent SEPSIS = Fecal diversion & Presacral drainage
  • Destructive injuries over 50% = Resection above the Injury w/ end-end Colostomy

general surgery (10 decks)

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