1. Chirurgia Generale Prof. A.L. Gaspari a.a. 2009/2010
Case Report
Chirurgia Generale Prof. A.L. Gaspari
a.a. 2009/2010

2. Start off with a case.

3. 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!

4. 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!

5. 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!

6. What to do FIRST?

7. What to do FIRST? ATLS!!!

8. What to do FIRST? ATLS!!!
PRIMARY SURVEY & RESUSCITATION: “ABCDE” rule

9. PRIMARY SURVEY
A :
B :
C :
D :
E :
1/00

10. PRIMARY SURVEY A : Airway with cervical spine protect. B : C : D : E :
1/00

11. PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
D :
E :
1/00

12. PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
C : Circulation --control external bleeding.
D :
E :
1/00

13. PRIMARY SURVEY A : Airway with cervical spine protect. B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E :
1/00

14. 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

15. PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???
1/00

16. PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???
control bleeding by direct pressure!!!!!!
1/00

17. PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???
control bleeding by direct pressure!!!!!!
(or at least, try!….)
1/00

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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!!

24. Case Presentation
Transfer to PTV emergency department
TRIAGE ???

25. Case Presentation Transfer to PTV emergency department TRIAGE ???
Patient general condition
Age
Type of trauma
Associated injuries

26. 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

27. 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

28. Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring

29. Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring
every hour or continuous monitoring !!!!!

30. Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring
every hour or continuous monitoring
Ventilatory rate and Pulse-oximetry

31. Physical Examination Abdominal Trauma Evaluation
BP and Pulse trend, ECG monitoring
every hour or continuous monitoring
Ventilatory rate and Pulse-oximetry
Inspection

32. 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

33. 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

34. 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?

35. Physical Examination Abdominal Trauma Evaluation
Auscultation

36. Physical Examination Abdominal Trauma Evaluation
Auscultation
Chest ventilation
Peristaltic activity

37. Physical Examination Abdominal Trauma Evaluation
Auscultation
Chest ventilation
Peristaltic activity
Palpation

38. Physical Examination Abdominal Trauma Evaluation
Auscultation
Chest ventilation
Peristaltic activity
Palpation
Rebound tenderness
Guarding
Pelvic instability
Digital pression for fractures assessment (ribs)

39. Physical Examination Abdominal Trauma Evaluation
Rectal examination (?)

40. Physical Examination Abdominal Trauma Evaluation
Rectal examination (?)
Prostate
Rectal tone

41. PVC and vascular access Abdominal Trauma Evaluation
Peripheral Venous Catheter (PVC)

42. 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!)

43. Resuscitation Abdominal Trauma Evaluation
Fluid therapy
Initial fluid therapy at least 1-2 L for adults
Warm fluids
Cristalloids or Colloids ???

44. Tube Insertion Abdominal Trauma Evaluation
Gastric tube….yes or no?

45. 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 !!!

46. 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!!)

47. Tube Insertion Abdominal Trauma Evaluation
Urinary catheter

48. Tube Insertion Abdominal Trauma Evaluation
Urinary catheter
Monitor urinary output

49. 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

50. Secondary Survey: imaging or OR? Abdominal Trauma Evaluation
Diagnostic Peritoneal Lavage (DPL)
Ultrasound Scanning
Computer Tomography
Laparoscopy
Immediate Laparotomy

51. DPL contraindications
Absolute
Patient needs laparotomy
Relative
Multiple previous operations
Pregnancy (Third trimester)

52. DPL Gross blood >10 ml Red cells >100,000 /mm3
White cells >500 /mm3
Amylase > 175u/dl
gross GI contents
bacteria on gram stain

53. DPL Simple Fast Economical Reliable accuracy 97.3 - 99.1 %
false positive %
false negative %

54. DPL Complication rate 1 - 1.7 % Oversensitive Lacks specificity
Fails to investigate
Complication rate
6-25% non-therapeutic
laparotomy rate!!!!!
Source
Amount
Continuation
Retroperitoneum %

55. CT scan contraindications
Absolute
Patient needs laparotomy
Unstable patient

56. CT scan
Non-invasive
Reliable Accuracy % Sensitivity % Specificity 100 %
Delineate specific organ injury
Haemoperitoneum > 100ml
Assesses the retroperitoneum

57. 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 ?

58. 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

59. Postoperative Vaccination on VIII P.O. Which vaccination? And why?
Haemophilus
Meningococcus
Streptococcus

60. 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

61. FAST Focused abdominal sonography for trauma
Reliability
accuracy %
sensitivity %
specificity %
Can detect 70 ml fluid

62. 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!!!!!!!

63. 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

64. 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

65. LPS Unsuitable for unstable patients Performed in operating room
Difficulty to examine retroperitoneum

66. 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)

67. 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

68. 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

69. Scout
Rx- like
Free-air?

70. Skull base (coronal and axial)
Skull base fractures?
Spine lesion?

71. Skull base (coronal and axial)
Skull base fractures?
Spine lesion?

72. Thorax. Contusion? Pneumothorax? Ribs’ fractures? Hemothorax?
Flail chest?

73. Thorax bases Pleural effusion? Food in stomach? Diafragmatic hernia?
Liver injuries?

74. 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

75. 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

76. 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

77. 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

78. 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

79. 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

80. CT abdomen
Pancreatic lesion?
Retroperitoneum?

81. Pelvic CT
Pelvic fractures?

82. Pelvic CT Douglas pouch: free intrabdominal fluid - heamoperitoneum?
Quantification of haemoperitoneum
Bladder?

83. Pelvic CT
Urethra?

84. Abdominal US (postop control)

85. 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

86. 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 ?

87. 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?

88. Observation
The patient were OBSERVED clinically monitoring vital signs (Pa, HR, sPO2, diuresis).
Blood count and coagulation every 2 hours

89. Observation

90. 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

91. Observation

92. Observation

93. Surgical managment
Laparotomy or Laparoscopy?

94. Surgical managment
The patient underwent a diagnostic laparoscopy and control of haemostasis.
Intraoperative finding:
800cc hemoperitoneum
2 splenic fractures

95. Surgical managment Haemostasis by Lavage Large abdominal drainage
Coagulation
Floseal
Tabotamp
Lavage
Large abdominal drainage

96. 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)

97. 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

98. 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

99. Traumatic splenic lesion. Surgical Treatment

100. Traumatic splenic lesion. Classification

101. Blunt Injury Abdominal Trauma
Spleen 25%
Liver 15%
Hollow viscus 15%
Ileum
Sigmoid
Kidney 12%
Retroperitoneal 13%
Mesentery 5%
Compression
Crushing
Shearing
Avulsion

102. 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?

103. 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

104. 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

105. Blunt Liver Trauma Protocol 1998

106. 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

107. 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”