Abdominal trauma management
156 likes29,835 views
1) Abdominal trauma is commonly encountered in the emergency department and can be challenging to diagnose due to subtle or delayed presentations of serious intra-abdominal injuries. 2) A thorough primary and secondary survey including vital signs monitoring, focused assessment with ultrasound, and diagnostic tests like CT scan are used to identify injuries. 3) Uncontrolled hemorrhage and sepsis are major causes of mortality, so prompt diagnosis and management of injuries is important to prevent complications.
Abdominal trauma management
- 2. Introduction Abdominal trauma is regularly encountered in the emergency department One of the leading cause of death and disability Identification of serious intra-abdominal injuries is often challenging Many injuries may not manifest during the initial assessment and treatment period
- 3. Epidemiology Peak incidence Abdominal Trauma 15 - 30yr More than 1.5 Lac people die every year as a result of injuries by motor vehicle accident , fall, suicide and homicide Injury accounts for 10% of all deaths Estimates indicate that by 2020, 8.4 million people will die yearly. Prevalence: 13%
- 4. Uncontrolled haemorrhage is the major acute cause of death immediately following abdominal trauma. Most common delayed cause of mortality and morbidity following abdominal trauma is sepsis.
- 5. Classification of Abdominal Trauma Trauma Blunt Crush injury Blast injury Seat Syndrome Penetrating Stab Wound Gun Shot Wound Iatrogenic Endoscopic External cardiac massage Peritoneal dialysis Per-cutaneous trans- hepatic cannulation Guided liver biopsy
- 6. Mechanism of injury Blunt trauma: MVC Seatbelt injury fall from ht crash injury sport injury Penetrating injuries.
- 7. Blunt trauma associated with severe trauma to multiple intraperitoneal organs and extra-abdominal systems altered mental status, intoxication Peritoneal signs are often subtle and may be obscured by other painful injuries Up to 20% of patients with hemoperitoneum have benign abdominal exams on initial presentation.
- 8. liver (40-55%) spleen (35-45%) Small bowel (5-10%) Retroperitoneal hematoma: 15%
- 10. Seat belt injuries Unrestrained front and rear seat passengers are at unequivocally greater risk of intra-abdominal injury than their restrained counterparts. The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries. However, abdominal injuries are still ascribed to shoulder-lap and lap-belt systems.
- 11. Clinically, two symptom patterns emerge. 1/4 of pt develop evidence of a hemoperitoneum secondary to mesenteric lacerations. In the remainder, the intestinal injury most commonly involves the jejunum contusion or perforation. Rare cases of acute abdominal aortic dissection with incomplete or complete occlusion have also been described, and injuries to the lumbar spine are not uncommon.
- 12. Penetrating trauma Stab wound gunshot
- 13. Stab wounds Knives are not the sole implement used in stabbings. Ice picks, pens, coat hangers, screwdrivers, and broken bottles. most commonly in the upper quadrants, the left more commonly than the right
- 14. multiple in 20% of cases involve the chest in up to 10% of cases. Most stab wounds do not cause an intraperitoneal injury the incidence varies with the direction of entry into the peritoneal cavity The liver, followed by the small bowel, is the organ most often damaged by stab wounds.
- 15. Gunshot wounds the degree of injury depends : amount of kinetic energy imparted by the bullet to the victim mass of the bullet and the square of its velocity Distance
- 17. Anaesthesists’ responsibility in trauma care 1.Prehospital care 2.Emergency department Trauma team leader Trauma team member Anaesthesiologist 3.Operating room Anaesthesia 4. Postoperative care Intensive care unit High-dependency unit Acute pain team 5. Transportation
- 18. PRE-HOSPITAL INFORMATION AND HANDOVER M-I-S-T MECHANISM OF INJURY INJURIES SUSTAINED OR SUSPECTED SIGNS- VITALS ON SCENE AND DURING TRANSPORT TREATMENT INITIATED
- 19. Prehospital Care The goal of prehospital is to deliver the pt to hospital for definitive care as rapidly as possible. ‘Scoop and Run’ Maintain airway & start I V line Care of spinal cord Communicate to medical control Rapid transport of patient to trauma centre
- 20. TRAUMA TEAM RADIOGRAPHER AIRWAY DOCTOR AIRWAY NURSE CIRCULATION DOCTOR CIRCULATION NURSE ORTHO REGISTRAR WARDSPERSON SCRIBE NURSETEAM LEADERSOCIAL WORKER
- 21. Initial assessment Preparation & Triage Primary survey Resuscitation Adjuncts to primary survey and resuscitation Secondary survey Adjuncts to secondary survey Post resuscitation monitoring and reevaluation Definitive care
- 22. The use of the following protective devices is recommended Goggles Gloves Fluid-impervious gowns or aprons Shoes covers and fluid- impervious leggings Mask Head covering
- 23. PRICIPLES OF INITIAL ASSESSMENT APPLY APPROPRIATE MONITORING DEVICES
- 24. PRICIPLES OF INITIAL ASSESSMENT OBTAIN HISTORY A-M-P-L-E & TETANUS STATUS AMPLE ALLERGY MEDICATION PAST HISTORY LAST FOOD EVENTS
- 25. PRICIPLES OF INITIAL ASSESSMENT PERFORM DETAILED SECONDARY SURVEY(HEAD TO TOE)
- 26. PRICIPLES OF INITIAL ASSESSMENT TRANSFER FOR DEFINITIVE CARE
- 27. PRICIPLES OF INITIAL ASSESSMENT APPLY APPROPRIATE MONITORING DEVICES OBTAIN HISTORY A-M-P-L-E & TETANUS STATUS RAPID PRIMARY SURVEY SIMULTANEOUS MANAGEMENT OF LIFE THREATNING INJURIES PERFORM DETAILED SECONDARY SURVEY(HEAD TO TOE) TRANSFER FOR DEFINITIVE CARE
- 28. Primary survey A Airway maintenance with cervical spine protection B Breathing and ventilation C Circulation with hemorrhage control D Disability : Neurological status E Exposure/Environmental control : completely undress the patient, but prevent hypothermia
- 29. Airway During resuscitation of any severely injured patient, the initial priorities are to ensure a clear, secure airway and to maintain adequate oxygenation. If the airway obstructed, immediate basic maneuvers such as chin lift or jaw thrust along with suction may temporarily relieve the obstruction. In semiconscious patient, an oropharyngeal or nasopharyngeal airway may help while preparing for more definitive management.
- 30. Intubation of the trachea with a cuffed tube remains the gold standard
- 31. BREATHING AND VENTILATION Do not confuse airway problem for ventilation problem Patent airway does not equal adequate ventilation. Need good gas exchange Oxygen in CO2 out Rapid assessment of RR SPO2 TRACHEA CHEST EXPANSION PERCUSSION AUSCULTATION
- 32. CIRCULATION AND HEMORRHAGE CONTROL ASSESS- PULSE RATE AND CHARACTER SKIN COLOUR AND TEMPERATURE CONSCIOUS LEVEL(GCS) CAPILLARY REFILL TIME DECREASED URINE OUTPUT HYPOTENSION-A LATE SIGN WHEN≥ 30% BLOOD VOLUME LOST. Stopping the bleeding : most important priority
- 33. MANAGEMENT OF CIRCULATION Control bleeding with direct pressure Splint limb fractures Insert 2 large bore IV cannulas in adults or cut down on long saphenous v Send off blood-cross match,coagulation screen,Hb, hct,biochemistry,blood alcohol level if req Intraosseous needle in children upto 10 yrs
- 34. DISABILITY AND NEUROLOGIC STATUS Disability assessed by AVPU scale A. Alert i.e. obeys commands V. Vocalizes-inappropriate or incomprehensible P. Responds to pain U. Unresponsive GLASGOW COMA SCORE
- 35. EXPOSURE
- 36. RESUSCITATION Protect/Secure airway & protect C-spine Breathing/Ventilation/Oxygenation Vigorous shock therapy At last two large - caliber IV line Crystalloid solution ( Ringer’s lactate 2~3 litter) Type-specific blood Surgical intervention Protect from Hypothermia : 39oC warm IV fluid Urinary/gastric catheters unless contraindication
- 37. AIRWAY MANAGEMENT CLEAR THE AIRWAY- SUCTION – FINGER SWEEP – HEMLICH’S MANOEUVRE HEAD TILT & CHIN LIFT ENDOTRACHEAL TUBE
- 39. Maintain SBP at 80-100 mmHg Maintain hematocrit at 25-30% Maintain the PT & PTT in normal ranges Maintain the platelet count at >50000/ HPF Maintain normal serum ionized calcium Maintain core temp higher than 35 C Maintain function of the pulse oximeter Prevent an increase in serum lactate prevent acidosis from worsening Achieve adequate anaesthesia and analgesia Goals for early resuscitation
- 40. Maintain SBP>100mmHg Maintain hematocrit above individual transfusion thresold Normalize coagulation status Normalize electrolyte balance Normalize body temperature Restore normal urine output Maximize CO by invasive or noninvasive means Reverse systemic acidosis Document decrease in lactate to normal range Goals of late resuscitation
- 41. PRIMARY SURVEY ADJUNCTS:- MONITOR VITALS ECG FOLEY’S CATHETER GASTRIC TUBE ABG PULSE OXIMETER URINE OUTPUT
- 42. PRICIPLES OF INITIAL ASSESSMENT APPLY APPROPRIATE MONITORING DEVICES
- 43. Secondary survey - Secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions.
- 44. Secondary Survey General &Systemic Examination-to identify all occult injuries . Special attention to Back, Axilla , Perineum PR - sphincter tone ,bleeding ,perforation , high riding prostate Foley’s catheter- monitor urine out put Nasogastric tube
- 45. Secondary Survey(contd.) AMPLE History A: Allergy M: Medications P: Past medical history L: Last meal E: Event - What happened
- 46. Examination Laceration Abrasion Entry/Exit wounds Involvement chest & Head injury Seat Belt Sign
- 47. Examination Cullen’s Sign:1918 Bluish discoloration around umbilicus Diffusion of blood along periumbilical tissues or falciform ligament Hemoperitoneum Severe pancreatitis
- 48. Examination Grey-Turner’s Sign: (1877-1951) Bluish discoloration of the flanks Retroperitoneal Hematoma hemorrhagic pancreatitis. Kehr’s sign (1862-1916). Referred pain, Right shoulder irritation of the diaphragm (Splenic injury, free air, intra-abdominal bleeding)
- 49. Examination Balance’s Sign Dullness on percussion of the left upper quadrant ruptured spleen Labia and Scrotum : Pooling of blood from abdominal and pelvic cavities.
- 50. A- Baseline labs They add little value in ruling out the need for surgical intervention yet they are mainly used for later on comparison. 1. HB : - quantity of blood to replace. 2. HCT : - confirm massive Hg (6-12 hrs). 3. WBCs : - indicate sepsis or reactive leucocytosis. 4. Serum createnin: - pre-renal shut down. 5. Glucose and electrolytes: - proper fluid resuscitation. 6. Amylase: - gut injury or pancreas (non-specific). 7. Urine analysis: - if RBCs >30 – 50 /mm, radiographic evaluation of kidneys and urinary bladder is a must.
- 51. Plain X-Ray Chest & Abdomen Pneumotharax, Haemothorax Free air under diaphragm Nasogastric tube, bowel loops in the chest Elevation of the both /Single diaphragm Lower Ribs # -Liver /Spleen Injury Ground Glass Appearance – Massive Hemoperitoneum Obliteration of Psoas Shadow –Retroperitoneal Bleeding #vertebra
- 52. Focused Assessment with Sonography in Trauma (FAST) First used in 1996 Rapid , Accurate Sensitivity 86- 99% Can detect 100 mL of blood Cost effective Four different views- Pericardiac Perihepatic Perisplenic Peripelvic space Eliminates unnecessary CT scans Helps in management plan
- 53. B- FAST (cont.) Advantages: - 1. Fast and non-invasive. 2. Bedside. 3. Portable Disadvantages: - 1. Operator dependent. 2. Limited by surgical emphysema and obesity. It must be clear that in a hemodynamically stable patient a positive FAST per se doesn’t indicate the need for surgical exploration.
- 55. C- Diagnostic peritoneal lavage (DPL) It has been the golden standard for the investigation of blunt abdominal injury for more than 30 years. Its accuracy is 97.3%. False-positive rate is 1.4%. False- negative rate is 1.3%. DPL is considered positive if: - 1. Return of 10 ml of non-clotting blood on insertion. 2. Lavage count of 100 000 red cells per mm (RCC). 3. 500 white cells per mm. 4. Amylase greater than 200 IU. 5. Presence of bile, faeces, bacteria.
- 56. C- Diagnostic peritoneal lavage (DPL) (cont.) Indications: - 1. Unconscious trauma patient with signs of abdominal injury. 2. Patient with suspected intra-abdominal injury and equivocal physical findings. 3. Patients with muitple injuries and unexplained shock. 4. Patients with spinal cord injury. 5. Intoxicated patients in whome abdominal injury is suspected.
- 57. C- Diagnostic peritoneal lavage (DPL) (cont.) Disadvantages: - The most frequent criticism is the rate of non-therapeutic laparotomy performed for positive cell count due to the balance between false-negative results and over sensitivity. Its various estimation is 10 - 15 %. It does not allow conservation management in the presence of blood in the abdominal cavity, but CT may be used as an adjunct in the stable patients.
- 58. C- Diagnostic peritoneal lavage (DPL) (cont.) Contraindications: - 1. Patients with previous abdominal operations. 2. Pregnancy. 3. Morbid obesity. 4. Patients with frank surgical abdomen. Complications: - 1. Gut perforation. 2. Hemorrhage. 3. Infection.
- 61. Paracentasis Four quadrant aspiration of abdomen A Positive tap – blood , air , bile stained fluid Negative tap doesn’t rule out injury. False negatives are as high as 22-60%
- 62. CT Scan • Gold Standard • Haemodynamically Stable • Provides excellent imaging of pancreas, duodenum and Genitourinary system • Standard for detection of solid organs injury. • Determines the source and amount of bleeding • Can reveal other associated injuries e.g. Vertebral & Pelvic # & injury in the thoracic cavity . • High Specificity-95%
- 63. DPL FAST CT SCAN Indications Document bleeding if hypotensive Document fluid if hypotensive Document organ injury if BP normal Advantages •Early diagnosis •All patients •Rapidly performed •Sensitivity 98% •Detects bowel injury •Transport : No •Early diagnosis •All patients • Rapidly performed •Non invasive •86- 97% accurate •Transport: No •Most specific for injury •Sensitive 92-98% Disadvantages •Invasive •Low specificity •Misses injury to diaphragm and retroperitoneum •Operator dependant •Bowel gas and subcutaneous air distortion •Misses injury to diaphragm ,bowel and pancreas •Increased cost and time •Transport required •Misses injury to diaphragm ,bowel and sometimes pancreas
- 64. UNSTABLE INVESTIGATION AVAILABILITY F A S T D P L FREE FLUID BLOOD NO YES CONTINUE RESUSCITATION LAPAROTOMY HEMODYNAMIC STABILITY ?
- 65. Blunt abdominal injuries carry a greater risk of morbidity and mortality than penetrating abdominal injuries
- 68. Indications for laprotomy BTA with hypotension, with clinical evidence of intraperitoneal bleeding BTA with positive DPL or FAST Hypotension with penetrating wounds Gunshot wounds traversing the peritoneal cavity or visceral/vascular retroperitoneum Evisceration Bleeding from the stomach, rectum or genitourinary tract following penetrating trauma
- 70. PREPARATION FOR ANESTHESIA AND SURGERY Establishing or Confirming Presence of Definitive Airway Intravenous Access. Evaluation of Preoperative Volume Status. A quick evaluation of the patient’s volume status can be made by measuring the blood pressure, heart rate, palpating the peripheral pulse, skin color and turgor, and quality of mucous membranes
- 71. INDUCTION AND MAINTENANCE OF ANESTHESIA Hypotension at induction of anesthesia for trauma is a common and important complication to avoid. suppression of endogenous catecholamines. direct myocardial depressant effects and vasodilator effects of certain induction drugs. once abdominal incision is made, tamponade of abdominal bleeding is lost and a torrent of bleeding may occur
- 72. INDUCTION It is frequently quoted that “more soldiers were killed in World War II by thiopental than by bullets.” Comatose patients, those in severe shock, or in full arrest on admission, require nothing more than oxygen and possibly a neuromuscular blocking drug until the patient’s blood pressure and heart rate rebound enough that anesthetics can be added. Awake traumatized patients demonstrating signs of hypovolemia are generally best induced with etomidate (0.2 mg/kg).
- 73. MAINTENANCE Drugs should be titrated according to BP. Trauma patients with hemorrhagic shock too severe to tolerate anesthetic drugs (other than neuromuscular blockade) should receive scopolamine as an amnestic. No absolute contraindications of any volatile drug for abdominal trauma . However, halothane and sevoflurane have been historically avoided due to potential for liver and renal injury, respectively. If possible, nitrous oxide (N2O) should be avoided to limit bowel and closed space gas accumulation.
- 74. ADJUNCTIVE MANAGEMENT AND COMPLICATIONS Administration of Shed Abdominal Blood. PREVIOUSLY CONTRAINDICATED. For noncontaminated intraabdominal blood involving liver, spleen, or retroperitoneal injury, cell saver technique is considered standard practice for most TRAUMA CENTRE. Prevent HYPOTHERMIA ACID BASE MANAGEMENT. ANTIBIOTICS.
- 75. POSTOPERATIVE ICU CONSIDERATION 1 • ABDOMINAL COMPARTMENT SYNDROME 2 • DEEP VENOUS THROMBOSIS 3 • SEPSIS
- 76. DAMAGE CONTROL Multi trauma pt. triad of coagulopathy, hypothermia, metabolic acidosis- interfernce with surgical mgt Goal- 1.control hmg 2. prevent contamination 3. protect pt. from further injury Proceed to definitive surgery once pt stabilises Clear communication between surgeon, anesthesiologist and intensivist
- 77. Getting the Right Care, at the Right Place, at the Right Time. Thank you