Management of blunt abdominal trauma

1
Management of blunt abdominal trauma

• Subash Gupta
• Gyan Burman Liver Surgery Unit
• Sir Ganga Ram Hospital
• New Delhi

2
Plan

• ABC of resuscitation
• ATLS
• DPL/US /CT scan
• Damage control surgery
• Specific issues in surgical care

3
(No Transcript)
4
Resuscitation

• Circulation
• Two large bore(16G)
• 2 L Ringers lactate
• Rapid responder surgical evaluation necessary
  initially
• Transient response ongoing loss/inadequate
  resuscitation, rapid surgical intervention
• Minimal or no response, immediate intervention
• Pump failure, myocardial contusion/tamponade
• Permissive hypotension,
• Pop the clot
• not with head injury

5
Permissive Hypotension for Trauma Resuscitation
Jon Hoerner, trauma.org (710) October
2002 Please mark my word. Within no less than 10
years, probably even less than 5 years, any one
that raises the blood pressure to higher than 3/4
the pre injury level, especially if using
crystalloid solutions will be severely criticized
as violating one of the indicators, whether the
injury be penetrating, blunt, elderly, child, or
one's own self or family. Also mark this down on
this date. The final target for a prehospital or
EC measured BP will be that greater than 80
SYSTOLIC will be the level that the QA moral
police will cite that those of you who believe in
two large bore IVs, Rapid infusors, interosseous
and sternal infursors, the 3 to 1 rule, and
cyclic hyper resuscitation as causing unnecessary
complications, deaths, and costs. Ken Mattox.
Trauma.Org Trauma-List, 30th August 2002
6
Abdominal trauma

• Peritoneal cavity major occult loss
• Assessment accurate diagnosis not important, but
  recognise that abdominal injury exists
• Special diagnostic tests
• Equivocal, unreliable, impractical
• Diagnostic lavage/CT scan
• FAST

7
Liver Trauma

• Conservative paradigm shift
• Before 1993, routine operative treatment
• Between 1993 - 1994, selective non operative
  management
• Between 1994 - 1998, non operative management
  standard practice

8
Conservative treatment

• Avoids laparotomy and complications of laparotomy
• Decreases blood transfusion
• High success rate irrespective of CT extent of
  injury, extent of haemoperitoneum
• No evidence to suggest missing of other injuries
• Contrast blush or ongoing haemorrhage indication
  for embolization

9
Liver trauma (contd.)

• Blunt
• Gunshot/penetrating explore
• Angiogram, bile duct complications
• Perihepatic packing

10
Operative technique

• Suturing
• Liver suture
• Resection
• ?Mesh compression
• Inflow occlusion

11
Operative technique

• Exposure and haemostasis
• Mobilisation
• Direct pressure, electrocautery, argon beam
  coagulation, finger fracture with direct ligation
  of bleeders
• Pringle manoeuvre,
• Avoid deep liver sutures
• Vascularised omental flap for tamponade

12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
Pancreas

• Explore and drain
• Distal pan/splenectomy
• Recognise duodenal injury
• Refer or call for help if needed
  pancreaticoduodenectomy
• Whipples resection (SGRH, lt 5 mortality)

21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
Spleen

• Conservation
• Key is to be able mobilise spleen outside the
  incision
• Delayed rupture ???
• Splenic conservation data??

26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
Damage Control surgery
31
Damage control

• Control haemorrhage and contamination
• Resuscitation correct hypothermia, acidosis and
  coagulopathy
• Return to OT definitive repair
• Post operative care

32
Damage Control Surgery

• Phase I
• Rapid termination of operative procedure
• Arrest of bleeding
• Removal of contamination
• Phase II
• Correction of physiologic abnormalities
• Acidosis, hypothermia, coagulopathy
• Phase III
• Definitive surgery

33
What is different?

• Surgical dogma complete the operation
• 1908 Pringle packing of liver injury
• Fell out of favour, not used in Vietnam war
• 1981 Feliciano 90 survival by packing in severe
  liver injury
• 1983 Stone abbreviated laparotomy, 11/17
  survivors
• Rotundo damage control surgery, 1990s

34
The lethal triad

• Bleeding coagulopathy
• Acidosis hypothermia

35
Hypothermia

• Fluids needed for resuscitation
• Exposure of body
• Large incision and long duration of procedure
• Blood loss, decreased O2 consumption and
  decreased heat production

36
Effects of hypothermia

• 100 mortality if core temp lt 32C
• Diminished cardiac function
• Coagulopathy clotting cascade is a temp.
  dependent reaction, fibrinolysis, platelet
  dysfunction/sequestration

37
Acidosis

• Lactate production from anaerobic metabolism
• Failure to normalize lactate concentration by 48
  hours, mortality between 86 to 100
• Systemic effects decreased contractility,
  impaired response to catecholamines and
  ventricular arrhythmias
• Coagulopathy worsened

38
Coagulopathy

• Dilution worsens coagulopathy
• Dilution and hypothermia additive
• Acidosis worsens coagulopathy

39
Damage control procedure

• ABC
• Life threatening bleeding rush to OR
• Temp elevated, Warm ventilator circuit, Bair
  hugger, early replacement of coagulation factors
• No effective guidelines when to initiate damage
  control

40
Abdomen

• Liver packing
• Ligation of blood vessels
• Placement of intraluminal shunts
• Chest tubes in to aorta or IVC
• Inflatable balloon catheters

41
Abdomen II

• Resect hollow viscus with stapler
• Biliopancreatic injuries by closed suction
  drainage
• Ligation of ureter or tube ureterostomy
• Formal closure
• Abdominal compartment syndrome
• ARDS
• MOF
• Closure of skin, mesh

42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
Stage II, resuscitation

• Similar principles as in OR
• ? Continuous arteriovenous rewarming
• Reduces time to normothermia
• Resuscitation requirements
• Early mortality
• Correction of acidosis Hyperchloremic acidosis
  versus lactic acidosis, anion gap narrow versus
  widened
• Correction of coagulopathy

46
Definitive operation

• Attempt to return to OR within 72 hours
• Remove packs
• Complete exploration
• Haemostasis
• Small bowel continuity
• Large bowel exteriorization

47
Abdominal compartment syndrome

• End organ dysfunction secondary to intraabdominal
  hypertension
• Tense abdomen,
• Elevated peak airway pressure
• Inadequate ventilation
• Inadequate oxygenation
• Oliguria
• Reversed with decompression
• Bladder pressure gt16mmHg
• Full blown syndrome gt35 mmHg
• Worse with fascial closure

48
Control of bleeding

• Bleeding DU, assistant to compress aorta against
  spine while taking stitches
• Leaking aneurysm mobilise left lobe, loop
  oesophagus divide crus of diaphragm and control
  supracoeliac aorta
• Ligation of internal iliac vessels if there is
  retroperitoneal bleeding, pelvic trauma

49
Summary

• Important to recognise when to stop operating
  stop the bleeding and deal with contamination
• Discretion is better part of valour
• Surgery should not be delayed till patient is
  adequately resuscitated, this can happen
  concurrently in OR.

50
(No Transcript)