Abdominal trauma |
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ABDOMINAL TRAUMA
Abdomen is the most commonly injured region after head and limbs. Evaluation of abdominal trauma especially blunt, may be difficult and hence every person involved in automobile, industrial or sports accident must be considered to have abdominal injury unless proved otherwise signs and symptoms of abdominal injury may be masked because altered consciousness and CNS injuries or may be subtle and delayed) Incidence of organ injury
Blunt trauma
Spleen 27% Kidney 24% Intestine 16% Liver 15% Abdominal wall 4%
Penetrating trauma
Liver 35% Spleen 26% Stomach 20% Colon 15% Vessels and retroperitoneum 10% Mesentery and peritoneum 10%
Types of abdominal trauma and mechanism
Blunt! Non perpetrating! closed abdominal trauma Penetrating / Open abdominal trauma Blunt abdominal trauma 75% of abdominal injuries occur following blunt trauma.
Severity of injury depends on
Speed of force and direction of force - higher rate of loading reduces tolerance of body tissue to injury. Size of force/amount of energy released Area over which the force is applied.
Mechanism of injury a)Crushing / compression - especially for solid organs since they are relatively fixed, exposed and compressed against the vertebral column b)Shearing - In solid organs or hollow organs occuring at junction of fixed and mobile portions leading to tears or perforations. e.g. Duodenojejunal flexures ,Ieocecal junction Extrahepatic biliary apparatus c)Bursting forces - due to application of blast wave resulting in a rapid increase in pressure especially in a hollow viscus - solid organs withstand blast wave better. Hollow viscus ruptures. d)Acceleration / deceleration / rotation
Differential inertia of motion producing strain Direct deformation of trauma Tensile strain - along long axis leading to stretch or compression Shearing strain - causing fracture or tearing Seat belt syndrome in automobile accidents with sudden deceleration. Transverse seat belt leads to sudden compression of mid abdomen. Leads to terminal Heal rupture with solid viscus injury. Also vertebral shear fracture occurs. Transverse band of contusion on abdomen seen. Nowadays therefore oblique shoulder seat belts used. Reduces risk of abdominal! chest trauma. Fracture clavicle common. Penetrating abdominal trauma Stab injury Long instrument with low velocity e.g. glass spike, wood, dagger, knife, screw driver, etc. Damage is primarily laceration or perforation confined to track of wound. Depends on size, shape, length and direction of the stab wound and region of abdomen penetrated Missile injury Amount of damage proportional to kinetic energy of the penetrating missile which depends upon the velocity and mass. Hence high velocity injury with a larger mass missile at a closer distance causes extensive injury not only along the missile track out also at right angles to it as it transmits energy and heat to the surrounding viscus causing thermal necrosis, shearing damage, stretching and tearing and temporary motion of the viscus away from the path of injury causing temporary cavitation. Also a missile body may fragment, ricochet, deflect or give rise to secondary missiles in form of fractured bone fragments thus causing multiple injuries not necessarily confined to missile track.
Features
Blunt abdominal trauma Evaluation is difficult since Associated multiple injuries to head, chest, extremities Intoxication /drug abuse No /minimal obvious external injury Solid organ injury is associated with slow bleed hence peritoneal signs may be lacking for the first few hours.
Penetrating trauma
Obvious wound and its extent Localised area of injury and hence an idea of nature of injury Perforation common hence peritonitis rapidly obvious
History
Duration extent and nature of trauma viz.- acceleration / deceleration / compression or of penetration viz, missile, stab, bullet, etc. Resistance or restraining device e.g. seat belts Relative position and direction of force especially for missile Associated injuries Unconsciousness, giddiness Pain in abdomen Distention of abdomen Urinary problems - hematuria Hematemesis, proctorrhagia, etc. Respiratory difficulty (rib fracture)
Examination
Systemic
Pulse and blood pressure (for shock) Orientation and CNS status Obvious head injury, limb fracture, etc. Respiratory embarrassment
Local
Of wound
Site, direction and extent for organs which could be damaged. Stab common on left side Entry and exit wound, especially look for areas where they may be hidden e.g. axillae, groin, gluteal clefts, inguinal folds, scrotum, flanks, etc. Palpate digitally for direction (avoid deep palpation) Look for foreign body or etiological evidence Check for respiratory system in upper abdominal stab wounds Evisceration
Inspection
Distension (localized/generalised) Echymoses / bruises / seat belt marks Signs of retroperitoneal hemorrhage viz. Grey Turner's sign - bluish discolouration of flanks Cullen's sign - periumbilical bluish discolouration
Palpation
Tenderness Guarding Rigidity Rebound tenderness Lump due to hepatic! splenic hem atoma Kehr's sign - pain at left shoulder tip increased on palpation in left hypochondrium with irritation of left hemidiaphragm with blood or bowel content.
Slow bleed, alcohol intake, drug intoxication, spinal cord injuries, etc. may mask these signs. Percussion Evidence of free fluid - dullness due to hemoperitoneum Balance's sign - shifting dullness on right side (due to hemoperitoneum) with fixed dullness on the left side (due to splenic hematoma)
Auscultation
Presence! absence of bowel sounds Vascular bruit Puddle *in for minimal hemoperitoneum
PR/PV examination
For pelvic bogginess For proctorrhagia For high floating prostate
Genital examination
Priapism (spinal injury) Loss of bladder control / acute retention Blood at urethral tip Perineal hematoma
Pelvis for fractures
Nasogastric tube
Continuos blood aspirate - hematemesis due to a penetrating stomach wound Eliminates acute gastric dilatation Gastric wash/lavage Decompresses bowel Removes foot and reduces operative contamination Reduces risk of aspiration Charts fluid loss and controls transluminal fluid fluxes Controls and reduces bowel oedema Avoids stomach injury during diagnostic lavage Facilitates wound closure without tension and reduces the risk of burst abdomen and other complications following exploration
Foleys catheter
Detect patency of lower urinary tract Detect hematuria Decompress bladder Chart urine output
Investigations and diagnostic procedures Hematological and other blood investigations
Blood grouping cross matching - for transfusion RBS, BUN, Electrolytes - Minimum operative fitness requirements ABG - if associated chest injury / respiratory distress Hb, CBC, PCV - leucocytosis >20000 without any infection or external blood loss suggest splenic rupture Serum amylase - pancreatic, duodenal or extrahepatic biliary radical injury SCOT/PT - liver damage
X-ray
Abdomen
Standing Supine/flat plate if patient unable to stand Lateral decubitus if patient unable to stand
Look for Free gas following perforating injury to the bowel Standing - under the diaphragm Decubitus - between abdominal wall and superior surface of the liver Double wall sign - gas on either side of bowel wall. Local visceral injury - increased density in that region due to hematoma, displacement of neighboring viscera, increased size of organ, localised ileus. Signs of intraperitoneal hemorrhage - flotation of bowel loops to centre of abdomen, separation of bowel loops by fluid density, ground glass appearance with increased density Localised / generalised ileus Retroperitoneal injury and hematoma - stippling, obliteration of psoas shadow. Traumatic diaphragmatic hernia Fracture of lower ribs / vertebrae / pelvis - idea of associated visceral injury, retroperitoneal or pelvic bleed, etc. Retained missile / foreign body in penetrating injury.
Other X-rays
X-ray chest Rib fracture Elevated diaphragm Diaphragmatic hernia Hemo/pneumothorax Pulmonary contusion X-ray pelvis with both hips X-ray skull in case of polytrauma
Diagnostic peritoneal tap / four quadrant tap / abdominal paracentesis Indications Suspected abdominal trauma in alcoholics, head injury, fractured rib. Any abdominal trauma with vague or equivocal findings Drugged/intoxicated individuals
Procedure
Ask patient to empty bladder. Rule out hepatosplenomegaly. Avoid sites of previous scars. Under LA introduce a 14 or 16 gauge spinal needle in the four extreme quadrants of the abdomen directing the needle at the parabolic gutters. Avoid rectus muscle to prevent.hematoma. Introduce through the abdominal wall till give way felt. Then apply negative suction.
Results Positive tap
0.1cc of non clotting blood Presence of bilious/fecal aspirate Presence of bacteria on examination
If the aspirated blood clots, the needle was probably in a blood vessel and not in the peritoneal cavity. It properly performed a positive tap is of 90% diagnostic accuracy. Negative tap is of no diagnostic significance.
Diagnostic Peritoneal Lavage (DPL)
First described by Root in 1960, hence called Root's lavage. It is safe and reliable and forms the mainstay of blunt trauma evaluation and also in certain cases of penetrating abdominal trauma Indications
Blunt trauma -
Patient with head injury, altered sensorium, drug intoxication, etc. Injury to ribs / vertebrae / pelvis Equivocal physical examination Equivocal / negative diagnostic peritoneal tap with persistent clinical suspicion
Penetrating trauma
Injury in flanks, back, lower chest upper gluteal region, etc. As in blunt trauma
Contraindications Absolute Unequivocal indication for exploration
Relative Dilated bowel Late pregnancy Scar of previous surgery Coagulopathy Significant abdominal wall hematoma following pelvic fracture
Technique
Nasogastric tube and Foleys to decompress. Aseptic precautions Under LA, 2-3 cm infraumbilical midline vertical incision 3-4cm at junction of upper and middle 1/3rd. Alternatively incision at inferior umbilical edge at left side. Incise deep layers upto peritoneum. Puncture peritoneum with trocar. Place a lexarous Nelsin / peritoneal dialysis catheter under direct vision. Alternatively blind percutaneous passage of guide wire through a hollow-needle followed a catheter. Aspirate, return of 20 cc or more of gross brood or obvious presence of fecal, small bowel or bilious content eliminates need for lavage and indicates need for exploration. It aspirate is negative give lavage using 1 litre of normal saline in adults (Children-10-15m1/kg) which is rapidly infused in the peritoneal cavity using a pressure device. Turn the patient from side to side. Then wait for 5-10 minutes. Lower the bottle and siphon of the fluid. Generally 200-300 ml returns. Positive DPL Presence of gross blood Presence of bile / feces / food content Lab tests RBC > 1 lac/cmm WBC > 500 /cmm Bacteria seen on Gram stain Significant amylase level Positive DPL indicates need for exploration Negative lavage with stable patient, close abdomen and observe the patient with periodic examination.
Disadvantages
Does not indicate the organ or nature of injury 5% are false positive Oversensitive to minor bleeds
X-ray abdomen always done before DPL, otherwise free air may be falsely positive later on.
USG
Identify organ of injury Ilematoma Flemoperitoneum Pelvic visceral injury
CT scan / contrast CT scan
Indications
Stable patients with closed head/spinal injury Stable patients with equivocal examination, diagnostic peritoneal tap & USG Patients with hematuria Suspected retroperitoneal pathology Pelvic fractures Delayed presentations
Advantages
Organ discrimination good Acute determination of nature and extent of injury Quantification of amount of free blood Retroperitoneum evaluation
Others investigations
Contrast studies - oral ingestion / RI feed of gastrograffin and look extravasation through perforation. Do not use barium. Not done nowadays. Angiogram : Shows vascular injury and vascular pattern Nowadays not used routinely. Specific indications. are Pelvic fractures with negative CT scan / DPL Therapeutic embolisation of deep pelvic bleeds Traumatic AV malformation Assess renal vascular damage Radionuclear scans : for solid organ damage, now not done routinely in emergency Laparoscopy Peritoneoscopy Endoscopy - especially if upper GI bleed Stabogram Local exploration of wound under LA - avoid blind probing MCU/DRU Bleeding per urethra Pelvic fracture/ laceration Strangury Perineal hematoma Mobile/high prostate on PR
Treatment of abdominal Trauma Exploratory laparotomy
Indications
Blunt trauma Unequivocal e/o hemoperitoneum Free gas on X-ray Persistent hypotension Positive DPT/DPL Non responding GI bleed Penetrating trauma Peritonitis Hemoperitoneum Free gas under diaphragm Positive DPT/DPL Hemetemesis / hematuria which is persistent Deep / multiple stab wounds
Avoid exploration if
Stable patient, no shock, hypotension Vague abdominal complaints, no e/o peritonitis Shallow stab / pellet wound Tangential wound in a stable patient Injury in back flanks Nil clinical and investigation finding
Observe such patients. It any deterioration, laparotomy is performed.
Preoperative preperation Hemodynamic stabilization Adequate airway and respiration maintainance CVP line Nasogastric tube and Foleys catheterization BUN, electrolytes Blood grouping, cross matching Prophylactic antibiotic coverage - cephalosporins with gentamicin and metronidazade Antitetanus prophylaxis Facilities for intraoperative radiological procedures If associated lower chest trauma. Put prophylactic ICD because small lung tear may occur with IPPR. Skin preperation and shaving from chin to knee so as a stemotomy / thoracotomy and saphenous vein graft removal in necessary.
General principles of surgery
Under GA Midline incision, adequately large Peritoneum not opened till type specific blood available On incising peritoneum, rapidly suck/mop to evacuate blood, peritoneal cavity contents, etc. Place self retaining retractors for better visualization If massive bleed, which is uncontrollable and patient is collapsing with no visible source, then compress the abdominal aorta or compress the descending aorta after performing a thoracotomy. Rapidly examine liver, spleen and kidney for hemorrhage, control bleed by pressure, ligation, clamping, sponge stich or gelfoam. Seal any perforation immediately by applying two Babcock forceps and crossing over or by applying non crushing (occlusion) clamps. Then repair in two layers. Irrigate with warm saline Place warm packs, especially on bowel Perform any vascular / solid organ repair Retroperitoneal hematoma - opened after complete lavage of peritoneal cavity and change of gloves. Hematoma opened only after complete repair of any perforation. Explore each organ minutely. If no obvious cause of bleeding identified then check. Undersurface of diaphragm Duodenojejunal flexure Retroduodenal portion Mesenteric border of intestine Lesser sac Prevent intraoperative hypothermia by Using warm blood / saline Lavage with warm saline Nasogastric tube, irrigation with warm saline Use of heating blankets If possible use of high flow blood warmers and heating cascades on anaesthetic machines. Bowel perforation / peritoneal contamination constitutes dirty wound. Give a thorough antibiotic solution lavage, place a drain and give post op irrigation Before closure always recheck and explore. Monolayer closure - fast and strong. Peritoneal and subcutaneous tissue closure increases chance of adhesions and hence avoided. Linea alba closed with continuos/ interlocking No. 1 protene. Always place multiple drains whenever perforation, pancreatic injury, solid organ hematoma, excessive dissection, bowel distention is present. Fast surgery performed. Minimise operating time. Specific organ injury and management Stab Wound Stab Injury
Gunshot/ missile wounds
96% chance of visceral injury on peritoneal penetration and hence usually explored. Some patients with no sign and symptoms, flank or bank wounds and negative DPL may indicate need for conservation and initial observation. Massive hemoperitoneum (surgical emergency) Patient is hypotensive, in shock with progressive distension of abdomen, tenderness, guarding, rigidity with no evidence of external bleed, pleural bleed (ruled out by X-ray). A retroperitoneal bleed (especially with pelvic fracture) requires only radiologic and vascular intervention. Hemoperitoneum requires emergency surgery it massive. 4 surgical options available
Left lateral thoracotomy and clamp aorta (in emergency room) Fogarty retrograde femoral artery aortic balloon introduction Stabilize BP to 80 mm Hg and then perform left lateral thoracotomy in OT. Immediate exploratory laparotomy and cross clamp supracoeliac aorta through lesser sac.
Abdominal wall
Hematoma may be due to rupture of rectus abdominis or injury to epigastria vessels. Guarding, rigidity often present and maybe confused with and even mask intra-abdominal injury. Differentiated form intra abdominal swelling by head raising. Large hematoma drained.
Liver
Most commonly injured in penetrating trauma Mechanism Direct blow Compression between ribs Vehicular injury Penetration - knife, rib stab/gunshot Shearing at fixed points kick/blow punch While major injury may cause obvious features minimal tears and lacerations may be missed Non operative management CT scan diagnosis needed.
Criteria - Stable patient of blunt trauma with Simple parenchymal laceration Small intrahepatic hematoma Intraperitoneal loss < 25 cc No active bleed Absence of any other injuries Unruptured subcapsular / intrahepatic hematoma
Procedure Bed rest Nasogastric aspirate Antibiotics Regular examination Regular SGOT/PT, USG/CT scan Gradual resumption of activity
Abandon conservation if Deterioration Transfusion needed regularly Increased collection Increased guarding / rigidity Progressive expansion of hematoma Suspected development of septic focus in hematoma Operative management Simple repair techniques i) Drainage Indications Minor bleeding parenchyma lesion Bleeding stops on its own/own compression [Class I wounds] Use a sump/penrose drain combination
Suture with drain
Indications Small capsular cracks / lacerations Minor avulsed vessels / ducts Minimal bleed after pressure Using 1-0/2-0 chromic catgut, take simple interrupted sutures 2cm from wound edge and tied over gel foam Application of topical agents Surgical (oxidised regenerated cellulose) Fibrin glue (fibrinogen with clotting factors and aprotinin) Used for superficial lacerations and Glisson's capsule avulsions.
Suture hepatorrhaphy For 1-3 cm deep peripheral penetrating wound or parenchyma laceration (Class II wound) Selective ligation of any major bleeder followed by 1-0 chromic catgut simple running sutures or horizontal matress sutures. Covered with surgical / glefoam. Advanced repair techniques i) Extensive hepatorrhaphy Indicated for - multiple deep lacerations (Class III/ class IV) Multiple deep horizontal matress sutures to arrest bleeding. Nowadays indications decreased due to risk of uncontrolled bleed, reapportion and extensive liver necrosis below sutures. " Hepatotomy with selective vascular ligation Bleeding deep laceration from stab / missile wounds. Blunt/finger dissection to lay open any superficial tract. Ligate ducts/bleeders with 5-0/6-0 prolene.
Omental pack Vascularised omental pedicle placed loosely in deep lobar lacerations and held in place by loose chromic catgut sutures. It acts by causing hemostasis, reduces necrosis, acts as filler and reduces risk of post operative abscess. iv §ional elebridement Indications - Loose ragged superficial friable partially devascularised liver tissue Friable tissue in hepatic laceration or missile wound tract Preferred to segmentectomy / lobectomy as large amount of liver tissue is spared. Risk of post operative infection and secondary hemorrhage is reduced after a resectional debridement.
Resection
Indicated in Persistent massive hemorrhage Massive shattering / crushing injury Associated IVC/Hepatic vein injury It can be Segmentectomy Lobectomy Partial / hemi / subtotal hepatectomy Massive resections debridement
Selective hepatic artery ligation Hepatic artery lobar branch ligated after dissection at porta hepatic. Limited since chance of hepatic or gall bladder necrosis is high. Associated venous bleeding and wrong artery ligated leads to high failure rate.
Vascular isolation Clamping aorta portal vasculature and 1VC, to repair 1VC, hepatic artery or other vascular injury.
Perihepatic packing - Packed temporarily and a second look is given after 2 weeks or after stabilization of patient. Early surgery preferred to reduce complications. Packing done in extensive bilobar injury, persistent bleed with patient unfit of rmajor surgery, complications such as coagulopathy, renal failure, hypothermia Spleen Commonly injured in both penetrating and blunt trauma due to Superficial position Large size Mobility Contact with ribs Attachment to other organs
These may cause the following form of injury
Capsular tears especially at attachment with ligaments to other organs Laceration with shearing! rib fracture Tears along illume and along segmental hematoma Subcapsular/intrasplenic hematoma Through and through wounds! lacerations Shattering and fragmentation |