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

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Presentation on theme: "Case Report Chirurgia Generale Prof. A.L. Gaspari a.a. 2009/2010."— Presentation transcript:

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

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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 passengers 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!

5 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 passengers 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! Hes all yours!...good luck!

6 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 passengers 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! Hes all yours!...good luck!...(TO THE PATIENT!!!!)

7 What to do FIRST?

8 What to do FIRST? ATLS!!!

9 PRIMARY SURVEY & RESUSCITATION: ABCDE rule

10 1/009 PRIMARY SURVEY PRIMARY SURVEY A : B : C : D : E :

11 1/0010 PRIMARY SURVEY PRIMARY SURVEY A : A : Airway with cervical spine protect. B : C : D : E :

12 1/0011 PRIMARY SURVEY PRIMARY SURVEY A : A : Airway with cervical spine protect. B : B : Breathing C : D : E :

13 1/0012 PRIMARY SURVEY PRIMARY SURVEY A : A : Airway with cervical spine protect. B : B : Breathing C : C : Circulation --control external bleeding. D : E :

14 1/0013 PRIMARY SURVEY PRIMARY SURVEY A : A : Airway with cervical spine protect. B : B : Breathing C : C : Circulation --control external bleeding. D : D : Disability or neurological status E :

15 1/0014 PRIMARY SURVEY PRIMARY SURVEY A : A : Airway with cervical spine protect. B : B : Breathing C : C : Circulation --control external bleeding. D : D : Disability or neurological status E :E E : Exposure (undress) & Environment (temp control)

16 1/0015 PRIMARY SURVEY PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY???

17 1/0016 PRIMARY SURVEY PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY??? control bleeding by direct pressure!!!!!!

18 1/0017 PRIMARY SURVEY PRIMARY SURVEY If there is evident bleeding, what to do IMMEDIATELY??? control bleeding by direct pressure!!!!!! (or at least, try!….)

19 1/0018 Resuscitation Airway - definite airway if there is any doubt about the pts 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

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

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

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

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 B Rt chest pain and bruising C Pulse 92, Bp 120/90, HgB 16.0, EKG normal D GCS 15

24 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!!

25 Case Presentation Transfer to PTV emergency department TRIAGE ???

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

27 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

28 Case Presentation Transfer to PTV emergency department TRIAGE ??? Patient general condition Age Type of trauma Associated injuries RED : Most critical injury

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

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

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

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

33 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

34 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

35 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?

36 Physical Examination Abdominal Trauma Evaluation Auscultation

37 Physical Examination Abdominal Trauma Evaluation Auscultation Chest ventilation Peristaltic activity

38 Physical Examination Abdominal Trauma Evaluation Auscultation Chest ventilation Peristaltic activity Palpation

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

40 Physical Examination Abdominal Trauma Evaluation Rectal examination (?)

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

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

43 PVC and vascular access Abdominal Trauma Evaluation PVC At least two G (large caliber) Complete blood count and chemistry and coagulation Blood cross-matching test (independently by Hb at presentation!)

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

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

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 !!!

47 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!!)

48 Tube Insertion Abdominal Trauma Evaluation Urinary catheter

49 Tube Insertion Abdominal Trauma Evaluation Urinary catheter Monitor urinary output

50 Tube Insertion Abdominal Trauma Evaluation Urinary catheter Monitor urinary output Caution!!! Inability to voidretrograde Pelvic fractureurethrogram or US! Blood at the meatus Scrotal/Peryneal Ecchymoses High riding prostate

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

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

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

54 DPL Simple Fast Economical Reliable accuracy % false positive % false negative %

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

56 CT scan contraindications Absolute Patient needs laparotomy Unstable patient

57 CT scan Non-invasive ReliableAccuracy % Sensitivity % Specificity100 % Delineate specific organ injury Haemoperitoneum > 100ml Assesses the retroperitoneum

58 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 ?

59 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

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

61 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

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

63 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!!!!!!!

64 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

65 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

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

67 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 Unstable patient Requires experience

68 X-Ray (in the past or complimentary) Abdominal Trauma Evaluation 1. C-spine 2. Chest AP High association of chest injuries and abdominal injuries Free air? 3. Pelvis

69 X-Ray (in the past or complimentary) Abdominal Trauma Evaluation 4. ? Urethrography (if hematuria) Keep good urinary output! Better evaluated with CT scan 5. Spine fracture Chance Fracture 20% small bowel injuries

70 Scout Rx- like Free-air?

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

72 Skull base (coronal and axial) Skull base fractures? Spine lesion?

73 Thorax. Contusion? Pneumothorax? Ribs fractures? Hemothorax? Flail chest?

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

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 :…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

81 CT abdomen Pancreatic lesion? Retroperitoneum?

82 Pelvic CT Pelvic fractures?

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

84 Pelvic CT Urethra?

85 Abdominal US (postop control)

86 Case Presentation Ct scan Grade II spleen laceration Intra abdominal free fluid. Perisplenic, small amount in Douglas pouch BUT haemodynamic stability persistent !!!!! CT abdomen: Spleen injury grade II

87 Case Presentation Ct scan 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 ?

88 Case Presentation Ct scan 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?

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

90 Observation

91 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

92 Observation

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94 Surgical managment Laparotomy or Laparoscopy?

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

96 Surgical managment Haemostasis by Coagulation Floseal Tabotamp Lavage Large abdominal drainage

97 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)

98 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

99 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

100 Traumatic splenic lesion. Surgical Treatment

101 Traumatic splenic lesion. Classification

102 Blunt Injury Abdominal Trauma Spleen25% Liver15% Hollow viscus15% Ileum Sigmoid Kidney 12% Retroperitoneal 13% Mesentery 5% Compression Crushing Shearing Avulsion

103 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?

104 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

105 Surgical management (contd) 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

106 Blunt Liver Trauma Protocol 1998

107 Outcome Nonoperative Less blood mortality 15% Vs up to 63% LOS shorter TIP decision to treat is base on the patient stability

108 Whats 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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