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Chirurgia Generale Prof. A.L. Gaspari a.a. 2009/2010
Case Report Chirurgia Generale Prof. A.L. Gaspari a.a. 2009/2010
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Start off with a case.
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Case Presentation Monday, 6.00h….On the way home from a night of bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the 90 km/h...in Viale di Tor Vergata. As usual, being drunk, the driver walks out of his car without a scratch. (...except for scratching his head in disbelief!) The passenger…not so lucky! Sunday, 1600h. On the way home from an afternoon of bongos in the park. 20 yo healthy, but not-so-smart male Trying to beat the 80 km/h... T-boned to passenger’s side… As usual, being drunk, he walks out of his car without a scratch. (...except for scratching his head in disbelief!) Brought in boarded and collared to your ED He’s all yours!
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Case Presentation Monday, 6.00h….On the way home from a night of bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the 90 km/h...in Viale di Tor Vergata. As usual, being drunk, the driver walks out of his car without a scratch. (...except for scratching his head in disbelief!) The passenger…not so lucky! He’s all yours!...good luck! Sunday, 1600h. On the way home from an afternoon of bongos in the park. 20 yo healthy, but not-so-smart male Trying to beat the 80 km/h... T-boned to passenger’s side… As usual, being drunk, he walks out of his car without a scratch. (...except for scratching his head in disbelief!) Brought in boarded and collared to your ED He’s all yours!
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Case Presentation Moday, 6.00h….On the way home from a night of bongos in the park. 20 yo healthy, but not-so-smart male His friend 21 yo at passenger’s side…even less smart! Trying to beat the 90 km/h...in Viale di Tor Vergata. As usual, being drunk, the driver walks out of his car without a scratch. (...except for scratching his head in disbelief!) The passenger…not so lucky! He’s all yours!...good luck!...(TO THE PATIENT!!!!) Sunday, 1600h. On the way home from an afternoon of bongos in the park. 20 yo healthy, but not-so-smart male Trying to beat the 80 km/h... T-boned to passenger’s side… As usual, being drunk, he walks out of his car without a scratch. (...except for scratching his head in disbelief!) Brought in boarded and collared to your ED He’s all yours!
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What to do FIRST?
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What to do FIRST? ATLS!!!
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What to do FIRST? ATLS!!! PRIMARY SURVEY & RESUSCITATION: “ABCDE” rule
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PRIMARY SURVEY A : B : C : D : E : 1/00
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PRIMARY SURVEY A : Airway with cervical spine protect. B : C : D : E :
1/00
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PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
D : E : 1/00
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PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
C : Circulation --control external bleeding. D : E : 1/00
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PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
C : Circulation --control external bleeding. D : Disability or neurological status E : 1/00
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PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
C : Circulation --control external bleeding. D : Disability or neurological status E : Exposure (undress) & Environment (temp control) 1/00
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PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???
1/00
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PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???
control bleeding by direct pressure!!!!!! 1/00
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PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???
control bleeding by direct pressure!!!!!! (or at least, try!….) 1/00
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Resuscitation Airway Breathing /Ventilation/Oxygenation Circulation
- definite airway if there is any doubt about the pt’s ability to maintain airway integrity. Breathing /Ventilation/Oxygenation - every injured pt should received supplement oxygen Circulation control bleeding by direct pressure or operative intervention minimum of two large caliber IV should be established pregnancy test for all female of child bearing age. Lactated Ringer is preferred & better if warm 1/00
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Case Presentation 25 year old male
Car-accident, trauma on his left side Left chest pain & no deformity Left shoulder pain (!!!) A good air entry
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Case Presentation 25 year old male
Car-accident, trauma on his left side Left chest pain & no deformity Left shoulder pain (!!!) A good air entry B Rt chest pain and bruising
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Case Presentation 25 year old male
Car-accident, trauma on his left side Left chest pain & no deformity Left shoulder pain (!!!) A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0 , EKG normal
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Case Presentation 25 year old male
Car-accident, trauma on his left side Left chest pain & no deformity Left shoulder pain (!!!) A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0 , EKG normal D GCS 15
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Case Presentation 25 year old male
Car-accident, trauma on his left side Left chest pain & no deformity Left shoulder pain (!!!) A good air entry, spO2 98% B Left chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0, Ht 46 , EKG normal D GCS 15 E Chest and flank abrasions LEFT SIDE!!
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Case Presentation Transfer to PTV emergency department TRIAGE ???
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Case Presentation Transfer to PTV emergency department TRIAGE ???
Patient general condition Age Type of trauma Associated injuries
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Case Presentation Transfer to PTV emergency department TRIAGE ???
Patient general condition Age Type of trauma Associated injuries RED : Most critical injury YELLOW : Less critical injured GREEN : No life or limb threatened injury BLACK : Death or obviously fatal injury
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Case Presentation RED : Most critical injury
Transfer to PTV emergency department TRIAGE ??? Patient general condition Age Type of trauma Associated injuries RED : Most critical injury
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Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring
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Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring every hour or continuous monitoring !!!!!
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Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring every hour or continuous monitoring Ventilatory rate and Pulse-oximetry
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Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring every hour or continuous monitoring Ventilatory rate and Pulse-oximetry Inspection
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Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring every hour or continuous monitoring Ventilatory rate and Pulse-oximetry Inspection Seat belt mark Skin lacerations Previous surgery scar
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PHYSICAL EXAMINATION Abdominal Trauma
Physical examination unreliable Head trauma Spinal cord injuries Alcohol intoxication Use of illicit drugs Injuries to adjacent structure Significant amount of blood present Analgesia
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Diagnostic Methods Abdominal Trauma
Physical examination Bruises, abrasion over the abdomen Abdominal pain or tenderness Absent bowel sounds Unexplained hypotension P/E equivocal or misleading.!!! Peritoneal sign falsely negative in 40% Peritoneal sign falsely positive in 20% 10% of all injuries are initially overlook WHY?
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Physical Examination Abdominal Trauma Evaluation
Auscultation
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Physical Examination Abdominal Trauma Evaluation
Auscultation Chest ventilation Peristaltic activity
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Physical Examination Abdominal Trauma Evaluation
Auscultation Chest ventilation Peristaltic activity Palpation
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Physical Examination Abdominal Trauma Evaluation
Auscultation Chest ventilation Peristaltic activity Palpation Rebound tenderness Guarding Pelvic instability Digital pression for fractures assessment (ribs)
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Physical Examination Abdominal Trauma Evaluation
Rectal examination (?)
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Physical Examination Abdominal Trauma Evaluation
Rectal examination (?) Prostate Rectal tone
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PVC and vascular access Abdominal Trauma Evaluation
Peripheral Venous Catheter (PVC)
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PVC and vascular access Abdominal Trauma Evaluation
At least two 16-18 G (large caliber) Complete blood count and chemistry and coagulation Blood cross-matching test (independently by Hb at presentation!)
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Resuscitation Abdominal Trauma Evaluation
Fluid therapy Initial fluid therapy at least 1-2 L for adults Warm fluids Cristalloids or Colloids ???
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Tube Insertion Abdominal Trauma Evaluation
Gastric tube….yes or no?
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Tube Insertion Abdominal Trauma Evaluation
Gastric tube Relieves distention (stomach in CT scan) If drunk or other altered mental status Decrease risk of unattended vomiting But can also induce it , risk of aspiration !!!
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Tube Insertion Abdominal Trauma Evaluation
Gastric tube Relieves distention (stomach in CT scan) If drunk or other altered mental status Decrease risk of unattended vomiting But can also induce it , risk of aspiration !!! Caution: Facial fracture/basilar skull fracture….(AFTER CT!!)
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Tube Insertion Abdominal Trauma Evaluation
Urinary catheter
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Tube Insertion Abdominal Trauma Evaluation
Urinary catheter Monitor urinary output
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Tube Insertion Abdominal Trauma Evaluation
Urinary catheter Monitor urinary output Caution!!! Inability to void retrograde Pelvic fracture urethrogram or US! Blood at the meatus Scrotal/Peryneal Ecchymoses High riding prostate
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Secondary Survey: imaging or OR? Abdominal Trauma Evaluation
Diagnostic Peritoneal Lavage (DPL) Ultrasound Scanning Computer Tomography Laparoscopy Immediate Laparotomy
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DPL contraindications
Absolute Patient needs laparotomy Relative Multiple previous operations Pregnancy (Third trimester)
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DPL Gross blood >10 ml Red cells >100,000 /mm3
White cells >500 /mm3 Amylase > 175u/dl gross GI contents bacteria on gram stain
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DPL Simple Fast Economical Reliable accuracy 97.3 - 99.1 %
false positive % false negative %
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DPL Complication rate 1 - 1.7 % Oversensitive Lacks specificity
Fails to investigate Complication rate 6-25% non-therapeutic laparotomy rate!!!!! Source Amount Continuation Retroperitoneum %
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CT scan contraindications
Absolute Patient needs laparotomy Unstable patient
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CT scan Non-invasive Reliable Accuracy % Sensitivity % Specificity 100 % Delineate specific organ injury Haemoperitoneum > 100ml Assesses the retroperitoneum
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CT scan Need for transfer to scanner Need cooperative patient
Complications related to contrast Ionizing radiation Cost + Time + Personnel Usefulness in hollow viscus and dyapragmatic injury ?
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Spleen Injuries CT scan will save 70 % of spleen
Observation X 72 hr Healing over 6 weeks OPSI (overwhelming post Splenectomy infection) < 1% of splenectomy , increase in children
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Postoperative Vaccination on VIII P.O. Which vaccination? And why?
Haemophilus Meningococcus Streptococcus
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FAST Focused abdominal sonography for trauma
To identify if the abdomen is the source of haemorrhage in unstable trauma patients ? - FLUID To evaluate those with no major risk factors for abdominal trauma
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FAST Focused abdominal sonography for trauma
Reliability accuracy % sensitivity % specificity % Can detect 70 ml fluid
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FAST Focused abdominal sonography for trauma
Safe (Non-invasive) Cheap Rapid Can be performed in resuscitation area Can be used to follow-up injuries being managed conservatively!!!!!!!
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FAST Focused abdominal sonography for trauma
Training required Inter-observer variation Pitfalls: subcutaneous emphysema & gas distension & morbid obesity Cannot determine type of fluid Inadequate detection of visceral perforation Accuracy improves on repeated scanning
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LPS (?) ONLY stable patient!!!!!!!
No extensive intra-abdominal adhesions Suction irrigator catheter Angled laparoscopes Experienced laparoscopic surgeon Can be used as adjunct to CT and allows direct visualisation of injury allows assessment of whether there is ongoing bleeding
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LPS Unsuitable for unstable patients Performed in operating room
Difficulty to examine retroperitoneum
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Choice? DPL CT Scan USS (FAST) Unstable patient
to assess for blood and need for laparotomy Stable patient to define site of injury may permit non-operative Tx Requires experience DPL CT Scan USS (FAST)
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X-Ray (in the past or complimentary) Abdominal Trauma Evaluation
C-spine Chest AP High association of chest injuries and abdominal injuries Free air? Pelvis
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X-Ray (in the past or complimentary) Abdominal Trauma Evaluation
? Urethrography (if hematuria) Keep good urinary output! Better evaluated with CT scan 5. Spine fracture Chance Fracture 20% small bowel injuries
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Scout Rx- like Free-air?
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Skull base (coronal and axial)
Skull base fractures? Spine lesion?
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Skull base (coronal and axial)
Skull base fractures? Spine lesion?
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Thorax. Contusion? Pneumothorax? Ribs’ fractures? Hemothorax?
Flail chest?
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Thorax bases Pleural effusion? Food in stomach? Diafragmatic hernia?
Liver injuries?
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CT abdomen :…si apprezzano multiple lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
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CT abdomen :…si apprezzano multiple lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
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CT abdomen :…si apprezzano multiple lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
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CT abdomen :…si apprezzano multiple lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
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CT abdomen :…si apprezzano multiple lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
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CT abdomen :…si apprezzano multiple lesioni fratturative della milza con discreta quota di versamento ematico lungo la doccia parieto colica sinistra e nello scavo pelvico, in rapporto ad emoperitoneo. Discreta quantità di versamento fluido anche in sede periepatica e lungo la doccia parieto colica destra. Conclusioni: rottura di milza con emoperitoneo si consiglia videat chirurgico urgente
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CT abdomen Pancreatic lesion? Retroperitoneum?
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Pelvic CT Pelvic fractures?
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Pelvic CT Douglas pouch: free intrabdominal fluid - heamoperitoneum?
Quantification of haemoperitoneum Bladder?
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Pelvic CT Urethra?
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Abdominal US (postop control)
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Case Presentation Ct scan BUT haemodynamic stability persistent !!!!!
Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade II
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Case Presentation Ct scan BUT haemodynamic stability persistent !!!!!
Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade II Spleen injury II grade with stable vital signs: Observation OR Laparotomy ?
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Case Presentation Ct scan BUT haemodynamic stability persistent !!!!!
Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade II Spleen injury II grade with stable vital signs: Observation OR Laparotomy ?......OR Laparoscopy?
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Observation The patient were OBSERVED clinically monitoring vital signs (Pa, HR, sPO2, diuresis). Blood count and coagulation every 2 hours
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Observation
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Observation The patient remained clinically stable but with valid diuresis BUT Rapid decrease of Hb and Ht and coagulative function impairment: Hb 16 >11.6 Ht 45 > 34 INR 1.2 > 1.5
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Observation
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Observation
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Surgical managment Laparotomy or Laparoscopy?
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Surgical managment The patient underwent a diagnostic laparoscopy and control of haemostasis. Intraoperative finding: 800cc hemoperitoneum 2 splenic fractures
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Surgical managment Haemostasis by Lavage Large abdominal drainage
Coagulation Floseal Tabotamp Lavage Large abdominal drainage
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Postoperative Regular course (no fever, no wound infection, no pleural effusion) Feeding on II P.O. Control: Abdominal US on VII P.O. (patient refused abdominal CT scan) Hb at discharge 13.7, no need of transfusion Discharge at VIII P.O. No need of vaccination! (OPSI)
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Postoperative Absolute rest at home for 4 weeks: avoid sports with physical contact, trauma, efforts…. RISK OF DELAYED RUPTURE OF THE SPLEEN!!! Blood 1 week Abdominal 1 month Outpatient 1 week and 1 month
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Abdominal US (control)
si documenta modica falda di versamento perisplenico, che si dispone sino in pelvi. La milza presenta disomogenee caratteristiche ecostrutturali, in particolar modo in corrispondenza del suo margine laterale, con presenza nel suo contesto di immagine lineariforme da riferire verosimilmente ad area di fibrosi. In considerazione del dato anamnestico, necessario stretto monitoraggio dei parametri ematochimici ed eventuale nuovo controllo TC
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Traumatic splenic lesion. Surgical Treatment
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Traumatic splenic lesion. Classification
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Blunt Injury Abdominal Trauma
Spleen 25% Liver 15% Hollow viscus 15% Ileum Sigmoid Kidney 12% Retroperitoneal 13% Mesentery 5% Compression Crushing Shearing Avulsion
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Investigations NEED TO HAVE AN HIGH INDEX OF SUSPICION
Depends on: -Haemodynamic stability -Other injuries present Urgency to treat Likelihood of intestinal injury Includes: -Lab studies -FAST Focused Assessment with Sonography for Trauma -DPL Diagnostic Peritoneal Lavage -CT scan - LPT/LPS?
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Surgical management A significant solid orgsan injuries will not heal spontaneously and surgical intervention is the only acceptable approach for it Pringle 1908 Once the diagnostic of Hemoperitoneum has been made, routinely the next goal of the surgeons will be to prepare the patient for surgery as rapidly and efficiently as possible Sclafani 1991
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Surgical management (cont’d)
Isolated severe blunt injury may be managed nonoperatively with better survival and less blood products use. Grindlinger 1998 TIP Patient selection Type of Trauma Age Associated injuries
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Blunt Liver Trauma Protocol 1998
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on the patient stability
Outcome Nonoperative Less blood mortality 15% Vs up to 63% LOS shorter TIP decision to treat is base on the patient stability
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What’s New in Abdominal Trauma
Diagnostic Ct, U/S Laparoscopy its impact is coming Therapeutic Nonoperative management Spleen & liver Non operative for liver gunshot “Damage control” laparotomy “Abdominal compartment syndrome”
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