1. Abdominal Trauma Ramon Garza III M.D.

2. Boundaries of Abdomen Superior- Diaphragm Inferior- Infragluteal fold Medial/Lateral- Entire circumference of torso

3. Abdominal Divisions Intrathoracic Abdomen True Abdomen* Pelvic Abdomen Retroperitoneal abdomen

4. Intrathoracic Abdomen

5. Pelvic Abdomen

6. Retroperitoneum

7. Blunt Abdominal Injuries 60% of abdominal injuries Liver, Spleen, and retroperitoneal hematomas are most common injuries Liver > Spleen Spleen more clinically significant

8. Penetrating Abdominal Injuries Handguns 80% Stab Wounds 20% Handguns = High Kinetic Energy = Higher Injury Potential

9. Initial Management ABC’s 2 Large Bore Peripheral IV’s –Above Diaphragm Resuscitate w/ LR/NSS –Especially important in TBI –Should not delay operative intervention Don’t forget CXR and Pelvic films as other sources of hemorrhage

10. Diagnostic Penetrating If HD unstable-> OR If HD stable: Obvious peritonitis -> OR Gun: KUB w/ markers, if tangential ? CT, no FAST Knife: check fascial integrity, CT, laparoscopy, DPL *CT should be… contrast x 3 ** If laparoscopy… careful w/ diaphragmatic injury -> tension pneumothorax

11. Diagnostic Blunt HD unstable -> FAST, Pelvic Film, DPL, vs OR HD Stable -> CT A/P, serial abd exam –CT can miss hollow viscous injury –Can trend amylase and lipase

12. F.A.S.T. Look at 4 sites –Right Subhepatic Space “Morrison’s Pouch” –Left Upper Quadrant –Pericystic Area (better to have no Foley) –Pericardial Space What to look for?

13. F.A.S.T of Morrison’s Pouch LIVER Kidney

14. F.A.S.T. Good for blunt abdominal trauma Not reliable for penetrating injuries except…. –to evaluate pericardial space

15. Diagnostic Peritoneal Lavage Positive findings in Blunt Trauma: –10cc blood on initial draw back –Greater than 100,000 RBC/mL –Enteric Contents Positive findings in Stab Wounds –10cc blood on initial draw back –Greater than 10,000 RBC/mL –Enteric Contents

16. How to perform DPL Pelvic X-ray- if fx incision cephalad to umbilicus Foley Catheter Prep/Drape 3cm vertical infraumbilical incision down to linea alba PD catheter directed into pelvis

17. How to perform a DPL Aspirate initially 1L warm NSS (10mL/Kg for children) Drop IV bag back to floor and let fluid siphon back into bag Analyze fluid

18. Decision for OR Foley Start broad spectrum Abx –D/c’d 24hrs post surgery even if hollow viscous injury (except colon) Tetanus prophylaxis: booster vs IG Prep from sternal notch to middle thighs

19. OR Vertical Midline Incision Evacuate obvious clots/blood Pack all 4 quadrants Can clamp aorta at diaphragmatic hiatus Obvious hollow viscous injuries-> rapidly controlled w/ staple vs running suture vs Babcocks

20. OR cont Allow anesthesia to catch up once bleeding controlled Stop and think about case and what to do next Avoid hypothermia from resuscitation Methodically Explore Abdomen If damage control-> minimize OR time and take to ICU to resuscitate

21. Specific Abdominal Injuries

22. Diaphragmatic Repair all injuries to avoid intraabdominal herniation Repair primarily w/ permanent suture or w/ prosthetic material if too large Early repair through abdomen Late repair can be transthoracic

23. Spleen Kehr’s sign: pain in L shoulder CT w/ blush-> Angio embolization If or have to mobilize tail of pancreas w/ spleen Try to use topical hemostatic agents to control bleeding No need to anticoagulate w/ post splenectomy thrombocytosis

24. Liver CT is best tool to evaluate liver injury Angio for liver injury w/ blush No strenuous activity x 3months Use Pringle maneuver to control bleeding –If does not work-> ? Bleed from hepatic vein vs replaced R hepatic artery Post operatively give D10 fluids and Factor VII may be needed for coagulopathic pts

25. Pringle Maneuver

26. Stomach Take down gastrocolic ligament from left side to medial Evaluate posterior portion of stomach Low threshold for VATs if diaphragmatic injury is also present to washout chest Rarely injured in blunt trauma

27. Duodenum Dx by imaging w/ GI contrast Kocher to evaluate Repair in two layers –Vicryl for inner layer –Silk for Lembert –Close transversely Drain periduodenal area Duodenum does not require drainage Can use jejunal patch, RY D-J, Trauma Whipple

28. Kocher Maneuver Right Kidney

29. Small Intestine Definitive repair should not be performed until all of the bowel is evaluated –Use Babcocks to control contamination Resect segments w/ >50% injured Débride devitalized portions of SI If shotgun injury w/ multiple enterotomies plan for repeat Ex-Lap Chance fx in lumbar spine-> check for SB injury (repeat CT w/ GI contrast)

30. Colon/Rectum If colon injury-> Abx 2-3 days Can perform primary repair if no hypotension, other significant organ injury, < 6hrs since injury, and EBL < 1L DRE to check for blood, sign of rectal injury Proctoscopy/Sigmoidoscopy to evaluate rectum

31. Retroperitoneal Hematomas Always Explore Penetrating Explore Penetrating