Solid Organ Trauma Flashcards
What are the neck zones?
Zone 1: from the clavicle to cricoid cartilage
Zone 2: from cricoid cartilage to the
angle of mandible
Zone 3: above the angle of mandible
What are the indications for neck exploration?
1-expanding hematoma 2- uncontrolled external hemorrhage 3- decreased carotid pulse at C6 4- stridor, hoarseness, dysphonia, hemoptysis 5- severe dysphagia, odynophagia 6- blood in oropharynx
General clinical features of penetrating injuries
1- Features of shock: pallor, tachycardia, hypotension, cold periphery, sweating, oliguria
2- abdominal distention
3- pain, tenderness, guarding and rigidity, dullness in flank on percussion
4- respiratory distress, cyanosis depending on amount of blood loss
5- bruising over skin of abdominal wall
6- Features of specific individual organ injuries
What type of ultrasound is used to identify blood in abdomen?
FAST can identify more blood more than 100ml
It is not reliable for bowel or penetrating injuries
It needs to be repeated frequently
What is the procedure of choice for a physiologically unstable blunt abdominal injury patient ?
Diagnostic peritoneal lavage (DPL)
- subumbilical lavage catheter
- infuse one liter of normal saline/ ringer’s lactate into peritoneal cavity
- change positions of patient and move from side to side
- aspirate fluid content to assess the content
How do we conclude that the patient should undergo exploratory surgery after a DPL?
- 10ml or more of gross blood
- more than 100 000/cu mm of RBC
- more than 500/cu mm of WBC
- more than 175 IU/dl of amylase
- presence of bile, bacteria, food particles, foreign bodies
+ DPL
What are the contraindications for DPL?
1- history of previous surgery (adhesions)
2- when laparotomy is indicated definitely
3- pregnancy
4- obesity
What is the procedure of choice in stable trauma patients?
CT scan
When do we use diagnostic laparoscopy (DL)?
In stable patients to verify the diagnosis and make sure nothing is wrong
What are the indications for emergency laparotomy?
- frank haemoperitoneum
- significant diagnostic peritoneal lavage
- haemodynamically unstable patients
- US or CT scan shows significant intra-abdominal injuries
What is the most commonly injured organ?
Liver
Why is the liver the most commonly injured organ?
- friable parenchyma, thin capsule, fixed position
- right lobe is more prone to injury from the ribs
- complaint ribs
- transmitted force
What are the mechanisms of liver injury?
- Compression against ribs or spine
- ligamentous attachment to diaphragm and posterior abdominal wall will tear due to shear forces during deceleration injury
- high-velocity bullet injuries (Burst injuries)
- low-velocity penetrating injury
~ Stab wounds
~ percutaneous biopsy
~ cholangiography
~ biliary drainage
~ TIPS
~ capsular tears, hematoma, bile leaks, arteriobiliary fistula, hemoperitoneum, & arterial aneurysms
> 3cm deep parenchymal laceration and subcapsular hematoma >3cm in diameter
OR
50% of surface area or expanding is which grade?
Grade III liver or splenic trauma
Grade II liver or splenic trauma diagnosis?
parenchymal laceration 1-3cm deep
Subscapular hematoma 1-3cm thick
OR
10 - 50% supscapular nonexpanding hematoma
Grade I diagnosis of liver or splenic trauma?
Subcapsular hematoma <1cm
Superficial laceration <1cm deep
OR
< 10% subcapsular non expanding hematoma
Grade IV hepatic or splenic trauma?
Parenchymal/subcapsular hematoma > 10cm in diameter
Lobar destruction
OR
ruptured intraparenchymal hematoma with active
Segmental or hilar vessels producing >25% devascularization of spleen
Grade V hepatic or splenic injury?
global destruction or devascularization of liver
OR
Completely shattered or avulsed spleen
Hilar vascular injury that devascularizes entire spleen
What incision should be done for liver trauma exploratory surgery?
Midline incision
Liver injury diagnosis and management
CT
PUSH (direct compression) - Pringle: occluding portal triad at foramen Winslow with fingers
Plug by embolisation
Pack the liver bed
Complications of liver trauma?
- recurrent bleeding
- hemobilia
- perihepatic abscess
- biliary fistula
- intrahepatic hematoma
- pulmonary complications
- coagulopathy
- hypoglycemia
why is the spleen commonly injured?
because of its mobility
mechanisms of splenic injury
stab wounds and gun shots
blunt trauma
LUQ abdominal surgery
when should we salvage the spleen?
in children
what are the contraindications for splenic salvage?
- SHOCKED patient
- patient with severe injury
- patient has protracted hypotension
- delay is anticipated in spleen repair attempt
elective splenectomy pre operative preparations?
- vaccinations
- platelets & blood transfusion
types of splenectomy
- complete
- partial (in a patient with good general condition)
- laparoscopic
- open
Post operative early complications of splenectomy (several hours)
- hemorrhage LUNG - atelectasis - pleural effusion - subphrenic abscess STOMACH - acute gastric dilatation (loss of all peristaltic waves) - vomiting - hematemesis - perforation - fistula PANCREAS - abscess - pancreatitis (accidental ligation of tail of pancreas) - fistula HAEMATOLOGICAL - increase in platelet count & WBC leading to thrombosis POSTSPLENECTOMY SEPTICAEMA - H.influenza - Strep pneumonia - N. meningitides
late complications (7-10 days) of splenectomy
- overwhelming postsplenectomy infection (OPSI)
post splenectomy sepsis syndrome - nonspecific flu like symptoms
what is Cullen’s sign? in splenic injury
inter peritoneal hemorrhage
bluish coloration around the umbilicus
What is Ballance sign?
dullness in left hypochondrium with no shifting
What is Kehr’s sign?
referred pain to the left shoulder due to fluid collection below the diaphragm
