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

Start off with a case.

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 light @ 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 light @ 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!

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 light @ 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 light @ 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!

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 light @ 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 light @ 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!

What to do FIRST?

What to do FIRST? ATLS!!!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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!!

Case Presentation Transfer to PTV emergency department TRIAGE ???

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

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

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

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

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

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

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

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

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

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 Evaluation Auscultation

Physical Examination Abdominal Trauma Evaluation Auscultation Chest ventilation Peristaltic activity

Physical Examination Abdominal Trauma Evaluation Auscultation Chest ventilation Peristaltic activity Palpation

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

Physical Examination Abdominal Trauma Evaluation Rectal examination (?)

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

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

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!)

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

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

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 !!!

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!!)

Tube Insertion Abdominal Trauma Evaluation Urinary catheter

Tube Insertion Abdominal Trauma Evaluation Urinary catheter Monitor urinary output

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

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

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

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

DPL Simple Fast Economical Reliable accuracy 97.3 - 99.1 % false positive 0.2 - 1.4 % false negative 1.2 - 1.3 %

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

CT scan contraindications Absolute Patient needs laparotomy Unstable patient

CT scan Non-invasive Reliable Accuracy 91 - 98.3 % Sensitivity 60 - 85 % Specificity 100 % Delineate specific organ injury Haemoperitoneum > 100ml Assesses the retroperitoneum

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 ?

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

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

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

FAST Focused abdominal sonography for trauma Reliability accuracy 86 - 97 % sensitivity 88 - 91.7 % specificity 94.7 - 99 % Can detect 70 ml fluid

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!!!!!!!

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

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

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

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)

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

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

Scout Rx- like Free-air?

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

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

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

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

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

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

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

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

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

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

CT abdomen Pancreatic lesion? Retroperitoneum?

Pelvic CT Pelvic fractures?

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

Pelvic CT Urethra?

Abdominal US (postop control)

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

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 ?

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?

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

Observation

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

Observation

Observation

Surgical managment Laparotomy or Laparoscopy?

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

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

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)

Postoperative Absolute rest at home for 4 weeks: avoid sports with physical contact, trauma, efforts…. RISK OF DELAYED RUPTURE OF THE SPLEEN!!! Blood count @ 1 week Abdominal US @ 1 month Outpatient control @ 1 week and 1 month

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

Traumatic splenic lesion. Surgical Treatment

Traumatic splenic lesion. Classification

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

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?

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

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

Blunt Liver Trauma Protocol 1998

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

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”