Diagnosis & Management of Acute Abdominal Trauma Trauma Services Ottawa Hospital

Economic Burden of Injury in Ontario 1996 Injury death 2,844 Hosp injuries 43,382 Non hosp injuries 693,630 Total injuries 739,856 Partial perm. Disa. 15,232 Total perm. Disa. 1,141 Total annual cost $2.9 billion

INTRODUCTION Abdominal Trauma Abdominal injuries present in 7-10% of admission Present in ~ 20% of all trauma surgeries ½ of preventable trauma death are related to inappropriate management of abdominal trauma Extra abdominal injuries are clues to the presence of injuries within the abdomen Abdominal injuries should be suspect in all trauma

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?

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

CLASSIFICATION Abdominal Trauma Penetrating High velocity (85% penetrate peritoneum) Low velocity (95% need surgery) Stab(1/3 do not penetrate the peritoneum, of those 50% need Sx) Blunt trauma High energy transfer (car accident) Low energy transfer (fall, fight)

Mandatory Exploration Abdominal Trauma Anterior abdominal gunshot Stab Local exploration Penetration of the fascia?? DPL Laparoscopy Laparotomy Serial observation Surgeon’s expertise

Initial management for stab wounds

Blunt Injuries Physical examination Investigation Case presentation Specific organ injuries Liver Spleen Small bowel

Epidemiology Injuries From Motor Vehicle Passenger Restraints Decrease mortality from MVC Increase morbidity Seat belt syndrome Lap belt injury in children C-spine injury Air bag

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

Physical Examination Abdominal Trauma Evaluation BP and Pulse trend Inspection Seat belt mark Skin lacerations Previous surgery scar

Physical Examination Abdominal Trauma Evaluation Auscultation Palpation Rebound tenderness Guarding Pregnancy Pelvic instability

Physical Examination Abdominal Trauma Evaluation Rectal examination Prostate Rectal tone Vaginal examination Gluteal fold Penetrating injuries = abdominal injuries

Tube Insertion Abdominal Trauma Evaluation 4- Gastric tube Relives distention Decrease risk of unattended vomiting But can induce it , risk of aspiration !!! Caution Facial fracture/basilar skull fracture

Tube Insertion Abdominal Trauma Evaluation Urinary catheter Monitor urinary output Caution Inability to void retrograde Pelvic fracture urethrogram Blood at the meatus U/S Scrotal Ecchymoses High riding prostate

Special Diagnostic Studies Abdominal Trauma Evaluation DPL U/S Ct abdomen & pelvis

X-Ray Abdominal Trauma Evaluation C-spine Chest AP +/- paper clips for penetrating injury High association of chest injuries and abdominal injuries Free air? Pelvis +/- paper clips for penetrating injury

Others X-Ray Abdominal Trauma Evaluation Urethrography 5. ? IVP for hematuria IV contrast Keep good urinary output Better CT scan 6. Spine fracture Chance Fracture 20% small bowel injuries

Case Presentation J.D. (3265709) -1 47 year old male Car felt on his Rt chest, LOC at scene? RUQ & Rt chest pain & deformity Rt shoulder A good air entry B Rt chest pain and bruising C Pulse 92, Bp 120/90 HgB 140 EKG , few PVC, CK 1485, Triponin t < .05 D GCS 15 E Chest abrasions Rt side

Case Presentation J.D. (3265709) -2 Ct scan Abdomen Chest Xray

CT scan J.D. (3265709) -2

Case Presentation J.D. (3265709) -2 Ct scan Grade III liver laceration Intra abdominal free fluid HgB decrease to 93 Liver injury 85 % observation 10% -15% mortality 15 % Laparotomy 60 % mortality

Surgical management A significant liver 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

Surgical management (cont’d) Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use. Grindlinger 1998 TIP Patient selection Type of Trauma Age Associated injuries

TIP Resuscitation ATLS Patient ‘s clinical condition Hemorrhage Persistent or recurrent hypotention Hemorrhage Prompt control of bleeding Judicious volume restoration Maintenance of pH and To TIP Duration of shock more critical than the amount of blood transfused

Blunt Liver Trauma Protocol 1998

Outcome J Trauma;1998, 45,360

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

Spleen Injuries Diagnosis CT scan will save 70 % of spleen Hemodynamic instability LUQ pain Left shoulder pain 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

Small Intestine Injuries Epidemiology 15% of all laparotomy High index of suspicion required Serial examination DPL diagnostic in 95 % Enhance by enzyme Increasing success with CT and laparoscopy Delay in diagnosis increase M & M

Retroperitoneal air

Blunt Trauma in Pregnancy Abdominal Evaluation ½ Injuries due to MVA Increase incidence of splenic injury and retroperitoneal bleed Placenta abruption 2-5% minor injuries 20-50% in major injuries

Blunt Trauma in Pregnancy Treatment Multidiciplinary approach Stabilization of mother status Avoid venocaval compression Used shielding during X-Ray Aggressive Hypotention treatment Establish gestational age Ultrasound C-section…Group decision

Blunt Trauma in Pregnancy Treatment-2 Abdominal evaluation DPL supraumbelical approach CT scan (5-10 cGy, Max is 10cGy) Pelvic X-ray Pelvic fracture: associated with fetal skull # Unstable pelvic fracture = c-section (10%) Monitoring in labor & delivery room Rh- : RhiG within 72 Hours

Epidemiology Multivariate Odd Ratio From 16,000 Patients Gross hematuria 3.62 Admission hypotension 3.53 Lower ribs fracture 2.58 Hemo/pneumothorax 2.49 Abdominal wall hematoma 1.96 Base deficit(HCO3 < 21) 1.77 Pelvic fracture 1.5 (Brad Chushing)

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”