1. CDR JOHN P WEI, USN MC MD 4th Medical Battalion, 4th MLG BSRF-12 ABDOMINAL TRAUMA

3. Types of abdominal trauma Anatomical regions of the abdomen Initial care and diagnosis Evaluation of patient with blunt and penetrating trauma Specific organ trauma Surgery for injuries

4. BLUNT ABDOMINAL TRAUMA Common causes of injury motor vehicle accidents fall from heights explosive blast injuries physical assault

5. BLUNT ABDOMINAL TRAUMA Solid organ injuries including liver, spleen, kidneys, pancreas Rupture of hollow viscus including small and large intestine, stomach, esophagus, and bladder Vascular injuries Bony fractures of pelvis and lumbar spine

6. PENETRATING ABDOMINAL TRAUMA Mechanism of wounding and organ damage Stab wounds with knife or other instruments Gunshot wounds Explosive injury with shrapnel or secondary projectiles

7. PENETRATING ABDOMINAL TRAUMA Small and large intestine most commonly injured Lacerations of solid organs Vascular injuries Trajectory of penetrating instrument and objects in its way

8. ANATOMY OF ABDOMEN True abdomen Pelvic abdomen Intrathoracic abdomen Pelvis Retroperitoneum

9. EVALUATION AND DIAGNOSISOF ABDOMINAL TRAUMA Airway, Breathing, Circulation History of injury and mechanism Physical examination and vital signs Radiologic studies Laboratory testing

10. Resuscitation & management priorities of major abdominal trauma: Control airway and breathing Stabilize circulation with volume infusion or blood Hemorrhage control Nasogastric tube and urinary catheter if no pelvic fracture Resuscitation & management priorities of major abdominal trauma: Control airway and breathing Stabilize circulation with volume infusion or blood Hemorrhage control Nasogastric tube and urinary catheter if no pelvic fracture EVALUATION AND DIAGNOSIS OF ABDOMINAL TRAUMA

11. HISTORY Blunt abdominal trauma Penetrating abdominal trauma PHYSICAL EXAMINATION General physical examination Examination of the abdomen HISTORY Blunt abdominal trauma Penetrating abdominal trauma PHYSICAL EXAMINATION General physical examination Examination of the abdomen EVALUATION AND DIAGNOSIS OF ABDOMINAL TRAUMA

12. Laboratory blood tests Urinalysis Radiological Studies (Plain abdominal X-ray,CXR) Peritoneal lavage (DPL) FAST U/S of abdomen CT scan of abdomen Laboratory blood tests Urinalysis Radiological Studies (Plain abdominal X-ray,CXR) Peritoneal lavage (DPL) FAST U/S of abdomen CT scan of abdomen EVALUATION AND DIAGNOSIS OF ABDOMINAL TRAUMA

13. Peritonitis Hypotensive shock Evisceration of viscus Positive diagnostic (DPL) Determination of finding on FAST or CAT scan INDICATIONS FOR EMERGENT SURGERY

14. DAMAGE CONTROL SURGERY Prep surgical field from neck to knees and from flank to flank Longitudinal incision form xiphoid to pubis Cell saver to reinfuse autologous blood if possible Urgent exploration with packing of all four quadrants of abdomen Serial controlled examination of each quadrant and organ Pack liver injuries and splenic injuries Control vascular injuries Close off perforated gastrointestinal tract Examine retroperitoneal structures

15. DAMAGE CONTROL SURGERY Avoid hypotension, hypothermia, acidosis leading to coagulopathy Repair or ligate vascular injuries Splenectomy if injured Repair or resect intestines Pack liver hemorrhage Pack and leave open abdomen if necessary Continue resuscitation and warming in ICU Come back another day

16. DAMAGE CONTROL SURGERY

22. Renal injuries on battlefield often complex injuries If laceration and hematoma from blunt injury, may observe If laceration from penetrating injury, may require nephrectomy to control bleeding Need for drains after surgery

23. DAMAGE CONTROL SURGERY Retroperitoneal injuries: Blunt trauma Penetrating trauma Potential vascular injuries Zone 1 Zone 2 Zone 3

24. DAMAGE CONTROL SURGERY Pancreatic injuries Duodenal injuries

25. DAMAGE CONTROL SURGERY Pancreatic injuries vary from simple contusions and lacerations to complex injuries of head of pancreas Complicated by concomitant duodenal injuries Strategy to control hemorrhage Drainage of injuries Secondary procedures to divert GI tract

26. DAMAGE CONTROL SURGERY Diaphragmatic injury

27. DAMAGE CONTROL SURGERY Diaphagmatic injuries require surgical repair to avoid herniation abdominal organs and compromise of pulmonary function Diaphagmatic injuries require surgical repair to avoid herniation abdominal organs and compromise of pulmonary function Place chest tubes pleural cavity to control pneumothorax Place chest tubes pleural cavity to control pneumothorax

28. DAMAGE CONTROL SURGERY

29. Surgical strategy depends on cause of intestine injury due to penetrating vs blunt vs explosive blast Degree of contamination Small versus large bowel Hemodynamic stability of patient Suture repair Stapled resection No anastamosis if clinically unstable

30. SUMMARY Abdominal injury with potential for many organ systems at risk Abdominal injury with potential for many organ systems at risk Blunt versus penetrating injuries Blunt versus penetrating injuries Surgery to repair damage and control hemorrhage from vascular structures and organs Surgery to repair damage and control hemorrhage from vascular structures and organs Damage control surgery to repair intestines defined by battlefield conditions Damage control surgery to repair intestines defined by battlefield conditions Stabilize and return for definitive repair Stabilize and return for definitive repair