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Critical Care > Abdominal Trauma > Flashcards

Abdominal Trauma Flashcards

1
Q

Pre-op preparation for trauma laparotomy

A
  • Adequate IV access
  • Prophylactic antibiotics
  • Reserve 6 units PC, FFP, plt con
  • Inform OT to prepare two large suction catheter, all necessary equipment, vascular clamp
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2
Q

Procedure for trauma laparotomy

A
  • Drape from suprasternal notch to mid-thigh
  • Long midline laparotomy
  • Inform anaes before entering peritoneum
  • Stop bleeding and spillage (remove clots then 4 quadrant packing)
  • Remove packing to identify bleeding
  • Deal with lesion in order of lethality
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3
Q

Order the following by greatest lethality:

Solid organ bleeding

Hollow viscus contamination

Mesentery bleeding

Major vessel bleeding

A

Major vessel bleeding

Solid organ bleeding

Mesentery bleeding

Hollow viscus contamination

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4
Q

Level of splenic injury determined by which factors

A
  • Size of hematoma
  • Extent of laceration
  • Involvement of segmental / hilar vessels
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5
Q

Level I splenic injury

A
  • subcapsular hematoma, <10% surface area
  • capsular laceration, <1cm parenchymal depth
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6
Q

Level II splenic injury

A
  • Hematoma
    • subcapsular, 10-50% surface area
    • intraparenchymal <5cm in diameter
  • Capsular tear not involving trabaecular vessel, 1-3 cm parenchymal depth
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7
Q

Level III splenic injury

A
  • Hematoma
    • Expanding subcapsular
    • Ruptured
    • Intraparenchymal > 5cm
  • Laceration >3cm or involving trabecular vessels
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8
Q

Level IV splenic injury

A

Laceration involving segmental or hilar vessels, leading to major devascularization (>25% of spleen)

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9
Q

Level IV splenic injury

A

Laceration involving segmental or hilar vessels, leading to major devascularization (>25% of spleen)

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10
Q

Level V splenic injury

A

Completely shattereed spleen

Hilar vascular injury which devascularizes spleen

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11
Q

Indication for laparotomy in splenic injury

A
  • Unstable
  • Penetrating injury
  • Other concomitant injury requiring laparotomy
  • Failed non-operative treatment
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12
Q

Procedure for splenectomy

A
  • Surgeon on right, left hand holding spleen
  • Mobilize lienorenal, splenophrenic, splenocolic ligament
  • Deliver spleen medially towards lap wound
  • Apply soft bowel clamp at hilum
  • Ligate short gastric arteries
  • Ligate splenic artery then splenic vessel
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12
Q

Procedure for splenectomy

A
  • Surgeon on right, left hand holding spleen
  • Mobilize lienorenal, splenophrenic, splenocolic ligament
  • Deliver spleen medially towards lap wound
  • Apply soft bowel clamp at hilum
  • Ligate short gastric arteries
  • Ligate splenic artery then splenic vessel
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13
Q

What is OPSI?

A

Overwhelming post splenic infection.

Life-threatening infection due to encapsulated bacteria

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13
Q

What is OPSI?

A

Overwhelming post splenic infection.

Life-threatening infection due to encapsulated bacteria

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14
Q

Most common encapsulated organisms that could cause OPSI

A

Streptococcus pneumoniae

Hemophilus influenzae

Neisseria menigitidis

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15
Q

Non-operative management of traumatic splenic injury

A
  • Bedrest
  • NPO
  • Close monitoring
  • Angioembolization
  • Surveillance CT in 24-48 hours
    *
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16
Q

Indications for surgery in traumatic liver injury

A
  • hemodynamically unstable
  • penetrating liver injury
  • concomitant internal injury
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17
Q

Techniques for liver hemostasis during laparotomy

A
  • Bimanual compression
  • Pringle maneuver
  • Perihepatic packing
  • Topical hemostatic agents
  • Parenchymal vessel ligation
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18
Q

Grade 1 Liver injury

A

Hematoma <10% of surface area

Capsular tear < 1 cm parenchymal

19
Q

Grade 2 liver injury

A

Subcapasular hematoma 10-50% or intraparenchymal <10cm

Capsular tear 1-3cm parenchymal depth, not involving trabecular vessel

20
Q

Grade 3 liver injury

A

subcapsular hematoma > 50% surface area OR

ruptured hematoma

intra-parenchymal hematoma > 10 cm / expanding OR

Laceration > 3cm parenchymal depth

21
Q

Grade 4 liver injury

A

Parenchymal disruption involving 25-75% of hepatic lobe or >3 Couinaud’s segemnts within 1 lobe

22
Q

Grade 5 liver injury

A

Parenchymal disruption involving > 75% hepatic lobe, >3 Couinaud’s segment within single lobe

Juxtahepatic venous injury

Hepatic avulsion

23
Q

Pringle’s maneuver

A

Compression of porta hepatis

No greater than 30 minutes

24
Q

Possible complications of traumatic liver injury

A
  • Hemorrhage
  • Biloma
  • Hemobilia
  • Hepatic necrosis
  • Cholecystitis
  • SIRS secondary to bile peritonitis
25
Q

Non-operative management for Grade IV/V +/- III

A
  • Close monitoring with ICU admission
  • A-line
  • Hemocue, u/O q1H
  • FU CT in 48-72 hours
26
Q

Factors for grading of duodenal injury

A
  • single or multi-segment
  • extent of hematoma
  • extent of laceration
  • location of disruption (D1,2,3,4)
27
Q

How to expose the duodenum and pancreas during laparotomy?

A
  • Kocherization of duodenum
  • Divide gastrocolic ligament (expose posterior D1, medial D2, anterior pancreas)
  • Divide retroperitoneum inferior to pancreas (inspect posterior pancreas)
  • Right medial visceral rotation (expose D3)
  • Mobilize ligament of Treitz (D4)
28
Q

Treatment for low grade duodenal injuries

A

Debridement + primary repair

  • Grade 1: suturing serosa in Lembert fashion
  • Grade 2:
    • debridement + full thickness repair
    • >3cm: resection + primary anastomosis
29
Q

Treatment options for intermediate grade duodenal injury

A
  • debridement + primary closure
  • resection + primary anastomosis
    • duodeno-duodenostomy
    • larger defect: roux en y
30
Q

Treatments for ampulla injury

A
  • limited ampullary injury: stenting or sphincteroplasty
  • extensive ampullary injury: whipple operation
31
Q

Treatment options for isolated extensive duodenal injuries

A
  • Pyloric exclusion
  • Duodenal diverticulization
  • Pancreaticoduodenectomy
32
Q

What is duodenal diverticulization of Berne? Draw.

A
  • suture repair of injury
  • antrectomy + end-side gastrojejunostomy (Polya)
  • tube duodenostomy
  • T tube drainage of CBD
33
Q

Factors involved in grading of pancreatic injury

A
  • ductal injury / tissue loss
  • involvement of main pancreatic duct + relationship to SMV
  • distal / proximal transection
34
Q

Definition of abdominal compartment syndrome

A

Sustained intraabdominal pressure >20mmHg associated with new organ failure

35
Q

Risk factors for IAH/ACS

A
  • diminished abdominal wall compliance (increase intra-thoracic pressure, major trauma/burns, prone etc)
  • increase intra-luminal contents
  • increase abdominal contents
  • Capillary leak/fluid resuscitation
36
Q

How to measure patient’s IAP

A

Bladder technique

  • Insert 3 way foley
  • Instill 25ml saline into balloon
  • Measure 30-60 sec after instillation for pressure after detrusor muscle relaxation
  • Measure in absence of abdominal wall contraction

**measure in mmHg, at end-expiration, in supine position

37
Q

IAH Grading

A
  • Grade I: 12-15 mmHg
  • Grade II: 16-20mmHg
  • Grade III: 21-25 mmHg
  • Grade IV: > 25mmHg
37
Q

IAH Grading

A
  • Grade I: 12-15 mmHg
  • Grade II: 16-20mmHg
  • Grade III: 21-25 mmHg
  • Grade IV: > 25mmHg
38
Q

What is primary ACS?

A

condition associated with injury/disease in the abdominopelvic region frequently requiring early surgical/radiological intervention

39
Q

Five pillars of medical treatment for ACS

A
  1. Evacuate intraluminal contents
  2. Evacuate intra-abdominal SOL
  3. Improve abdominal wall compliance
  4. Optimize fluid administration
  5. Optimize systemic/regional perfusion
40
Q

Elaborate on progressive steps to evacuate intraluminal contents for medical management of ACS

A
  • insert nasogastric/rectal tube for decompression
  • initiate prokinetic agents
  • minimize enteral nutrition
  • administer enemas
  • consider colonoscopic decompression
  • discontinue enteral nutrition
  • consider surgical decompression if IAP still > 25 mmHg
41
Q

Elaborate on progressive steps to evacuate intra-abdominal space occupying lesions for medical management of ACS

A
  • abdominal USG/CT to identify lesions
  • Percutaneous catheter drainage
  • Consider surgical evacuation of lesions
42
Q

Elaborate on progressive steps to improve abdominal wall compliance for medical management of ACS

A
  • Ensure adequate sedation & analgesics
  • Remove constrictive dressings/ abdominal escars
  • Avoid prone position, avoid elevate head of bed >20 degrees
  • Consider reverse Trendelenburg
  • Consider neuromuscular blockade
43
Q

Elaborate on progressive steps to optimization of fluid administration for medical management of ACS

A
  • avoid excessive fluid administration
  • aim for zero to negative fluid balance by D3
  • resuscitate with hypertonic fluids/ colloids
  • Fluid removal via judicious diuresis
  • Consider hemodialysis /ultrafiltration
44
Q

Elaborate on progressive steps to optimize systemic/regional perfusion for medical management of ACS

A
  • Goal-directed fluid resuscitation
  • Maintain abdominal perfusion pressure > 60mmHg
  • Hemodynamic monitoring to guide resuscitation
  • Vasoactive medication to keep APP > 60mmHg
45
Q

Describe the sandwich technique

A
  • Sheet of self-adhesive drape (Ioban/Opsite) placed flat
  • Place abdominal pad on top
  • Fold edges of Ioban over abdominal pad producing membrane of one side of abdominal pad
  • Place on on-lay manner with membrane in contact with bowel
  • Place two closed system suction drains and apply low vaccum suction
  • Cover system by another occlusive adhesive drape
46
Q

Complications of open abdomen

A

Fluid loss

Protein loss

Fistula formation

Loss of domain (fascial retraction)

Critical Care (12 decks)

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