47-48 Abdominal Trauma Blunt and Penetrating Flashcards
What is the main cause of ABDOMINAL Blunt trauma
- motor vehicle & motorcycle accidents- >rapid decellaration injuries causing shearing of vessels nerves and contusion of solid organs
- falls,
- assaults,
- struck pedestrians
causes of ABDOMINAL penetrating trauma
according to the book
-
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.
-
mech = Medium-velocity or high-velocity injuries
-
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.
- smaller number of shotgun wounds.
2 ways of CLASSIFICATION of ABDOMINAL TRAUMA
A. According to the integrity of skin and parietal peritoneum
-
Open – skin and skin structures are damaged.
- penetrating – parietal peritoneum is damaged.
- non penetrating – parietal peritoneum is safe.
- 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
Clinical signs and symptoms in abdominal blunt trauma
perforated hollow viscera: (signs of peritonitis)
liver hematoma
- Positive sign of peritoneal irritation (Blumberg)
- Positive sign of muscle rigidity
- Presence of defense of abdominal muscles (Guarding
- 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
Clinical signs and symptoms of acute abdominal hemorrhage
THOPP
- Tachycardia – pulse rate over 100/min.
- Hypotension – systolic blood pressure under 100 mm/Hg.
- Oliguria/Anuria – urine outflow under 40 ml/our.
- Pale face
- Pulse on a.radialis – filiformis. (thready pulse)
BLunt trauma dg algorithm
what is used for stable pts
first choice for unstable
indicatios of DPL
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
- pre hospital trauma care with Advanced Trauma Life Support
- Imaging to asses LOCATION and EXTENT of abdominal injury
-
FAST exam for hemoperitoneum I/D is first choice in stable pt
- replaced DPL as t’s non invasive
- May be inneficative
- CT - stable pt’s only
- detects retroperitoneal hematomas and free fluid in abdomen
- if fast is inconclusive
- X-ray is less effective than both Fast and CT
- used to detect fractures
-
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
-
FAST exam for hemoperitoneum I/D is first choice in stable pt
Penetrating trauma algorithm
COnservative management of blunt trauma
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.
Indications for Laparotomy
- Hemodynamic instability
- Intra-abdominal bleeding detected on imaging
- Signs of peritonitis (guarding, rebound tenderness/distension, nausea/vom)
how is emergency laparotomy performed
- Patients who require laparotomy should undergo a systematic exploration so that all areas of the abdomen are assessed and injuries are not missed.
- Abdomen is opened from the xiphoid process to pubic symphysis to provide adequate exposure of all abdominal structures.
- falciform ligament is divided, separating the liver from the abdominal wall to improve retraction and perihepatic packing.
- 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.
- 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.
- Areas stained with blood that are of concern for injury should be explored further with careful dissection.
SPecific types of abdominal injury
most common types of injuries in Abdominal trauma
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
blunt traumas to the Liver from novakov book
- cause
- types of injury
- treatment
*
-
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)
- undet_ected hematomas_ -present as
TX- Large haematomas require ligation of bleeding vessels
spleen
which is preffered splenorrhaphy or Splenectomy
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
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
- 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
- Acute increase in INtraluminal pressure from external forces causing the gastric wall to burst. this leads to the specific pathologies.
- 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
- hematomas- evacuation of large ones to prevent spillage
- Full thickness perforation- Debridement of non viable tissue
- total / partial gastrecetomy with BILROTH reconstruction
MC side effect of gastrointestinal surgery
https://www.youtube.com/watch?v=mXhNYj_oqEU
DUMPING syndrome
abdominal trauma to the duodenum
type of trauma
age group commonly affected by blunt trauma
sx
complications
which associated pathology req surgical eploration
tx
- 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
what is GOO
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.
what is Succussion splash
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
TX of duodenal traumas
hematomas
transection
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
what is kochers maneouver
dissection of the lateral peritoneal attachments of the duodenum to allow inspection of the retroperitoneal structures such as the duodenum, pancreas
abdomina trauma to the Pancrea
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
what is the whipple procedure AKA PANCREATODUODENECTOMY
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
basic pancreatic anatomy and physio refresh
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
Four SIRS criteria https://www.youtube.com/watch?v=gAUvUZflLBc&list=PLwp4F9YlR_ss46Ag83UpQKPXsA0A36yNZ&index=5
- tachycardia (heart rate >90 beats/min),
- tachypnea (respiratory rate >20 breaths/min),
- fever or hypothermia (temperature >38 or <36 °C),
-
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
abdominal trauma to the small intestines
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
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
- 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
Rectal injuries
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
