Blunt Abdominal Trauma Col Rajan Chaudhry VSM Prof & HOD

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Blunt Abdominal Trauma

• Col Rajan Chaudhry VSM
• Prof HOD Surgery
• AFMC

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Armed Forces Medical College
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• Majority of preventable trauma deaths are due to
  unrecognized intra-abdominal haemorrage(West JC,
  Trunkey DD and Lim RC System of trauma care a
  study of two counties. Arch Surg 1979114455)
• 6 of all patients with blunt abdominal trauma
  will require laparotomy

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Mechanism

• Compression/crushing injuries to hollow viscus
• Deceleration injuries to spleen and liver
• Motor vehicle trauma
• Assaults
• Falls

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BAT - Mechanism

• Road Traffic Accidents 75
• Solid Organ injury liver / spleen with or
  without rib fractures
• Kidney Loin injury
• Crush between vertebral column wall neck of
  pancreas, intestine

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Initial Evaluation

• See patient in totality so as not to miss other
  organ system injuries
• Primary Survey ABC
• Secondary Survey during resuscitation
• Tertiary Survey after resuscitation

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Initial Management

• Start IV Line Ringer Lactate
• Catheterize unstable, peritoneal signs
• Send base line investigations including Blood
  Grouping
• Monitor vital parameters

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Is there hypoperfusion?

• Hypotension
• Tachycardia
• Cold clammy skin
• Reasons
• Cardiac compression tension pneumothorax,
  cardiac tamponade
• Bleeding abdomen, chest, extremities

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Abdominal Examination

• Evaluation distracted by intoxication, head
  injury, spinal injury
• Half the patients with no clinical findings have
  findings at laparotomy
• Despite this repeated clinical examination is the
  most important factor in decreasing mortality
• Clinical exam has 65 sensitivity

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What do you see

• Progressing abdominal distention
• Peritonism likely hollow viscus injury
• Bruises or seat belt marks
• Do not miss lower chest wall upper abdomen is
  intra thoracic
• Blood in peritoneal cavity seldom produces
  peritoneal signs

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Next question that needs to be answered

• Who are the patients who require immediate
  laparotomy?
• Who are the patients who require further
  investigations? If so, which investigation.

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Patients requiring immediate laparotomy

• Haemodynamically unstable with progressive
  abdominal distention
• Patients with peritoneal signs guarding,
  rigidity, rebound tenderness

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Who requires further evaluation

• Equivocal abdominal examination
• Concurrent chest injury
• Haematuria
• Diminished level of consciousness
• Other injuries requiring GA
• Extremes of age

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Investigations - Evaluation

• Ultrasound FAST (Focussed Abdominal Sonography
  in Trauma
• Done by Emergency doctor or surgeon
• Detects free fluid
• Solid organ injury
• Evaluates chest

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DPL

• Invasive Investigation
• Used to decrease incidence of negative laparotomy
• 1 L of saline infused into the abdomen
• Returning fluid evaluated for
• - RBC gt 1,00,000/ML
• - WBC gt 500/ ML
• - Bacteria

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CT

• Best for solid organ injury
• Retroperitoneum
• Grading of solid organ injury
• Part of NOM
• Quantifies fluid/blood in peritoneal cavity

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CT Indications

• Haemodynamically stable
• Altered sensorium head injury, drucs
• Equivocal clinical signs
• Pelvic fractures
• GA for other injuries
• Non Operative management

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CT Contraindications

• Unstable patient
• Obvious need for laparotomy
• Contrast allergy

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Laparoscopy

• Limited role in blunt abdominal injury
• More useful for penetrating abdominal injury
  where there is a question of peritoneal
  perforation or diagphragmatic injury
• Requires GA and risks of tension pneumothorax and
  air embolus

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Laparotomy

• Midline incision
• Prepare for hypotension on opening abdomen
• Pack all four quadrants
• Suck our blood

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Laparotomy

• Once stable, packs are systematically removed.
  Aim to uncover most likely injury last
• Bleeding sites controlled with clamps, sutures or
  repacking
• Gross contamination from GI tract controlled with
  sutures or staples

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Laparotomy

• Once haemorrhage and contamination controlled,
  systematic inspection is performedLiver
  spleenStomach - ant post wallEntire large
  small bowel(inc duodenum)Diaphragm
  gastrohepatic ligamentPancreas - Head, body
  tailCentral retroperitoneal haematoma

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Non Operative Management

• Liver injuryInitially tried on blunt liver
  injuriesSuccess predicted by stability of
  patient and independent on degree of
  injuriesgt98 success
• Spleen injuryChildren gt90 successAdults with
  mild-moderate spleen injuries

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Summary

• Be aware of possibility of intraabdominal injury
  in trauma patients
• If unstable - FAST or DPL
• If stable - CT scan of abdomen
• Systematic approach to laparotomy

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Penetrating Abdominal Trauma
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Mechanism

• Stab injuries
• Low Velocity Missile injuries
• High Velocity Missile Injury

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High Velocity Missile Injury

• Multi-organ involvement
• Mortality
• Stab wounds 0 - 3
• GSW (civil) 9 -13
• War wounds ??
• Cornwell 2001

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High Velocity Missile Injury

• Time between injury surgery of cardinal
  importance
• Mortality rises steeply if gap gt 8h
• Factors having adverse effect
• shock due to blood loss
• peritonitis due to gut perforation
• septicemia

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• Speedy evacuation to hospital
• Preferably heptr evac
• Minimal investigations
• Only Hb Blood grouping
• Resuscitation while shifting to OT, or on the
  table

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Penetrating Abdominal Injury

• Area nipples to mid thigh suspect abdominal
  injury
• Penetration lower chest injury to liver,
  spleen, diaphragm
• Thigh, gluteal region pelvis, rectum
• Back spine injury, kidney

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Initial Management (Including Pre hospital)

• IV Lines
• Antibiotics Omnatax, Amikacin, Flagyl
• NG Tubes empty stomach contents
• Urinary catheter monitor urine output,
  unsuspected kidney injury
• Tetanus Toxoid
• Keep patient warm

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Guidelines

• Haemodynamically unstable Needs urgent Surgery
• Minimal Investigations HB, Blood Grouping
• Resuscitation on way to theatre or on table

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Concept of controlled resuscitation(Hypotensive,
Limited, Balanced)

• Raising BP with fluid resuscitation may dislodge
  established clot more bleeding
• Awaiting surgery transfer, multiple cas
• Resuscitation to maintain adequate perfusion
• Regains consciousness, palpable radial, SBP 90mm

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Guidelines

• Signs of peritonism Needs early surgery
• IV Fluids
• Antibiotics
• Baseline investigations
• Injury to surgery time lt 6h

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Guidelines

• Evisceration cover with sterile towel
• Do not push back
• All need laparotomy
• Urgency as per haemodynamic status

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Role of Investigations (Imaging)

• Haemodynamic instability No role
• High Velocity missile injury all require
  surgery
• Role in stab wounds or low velocity missile
  injuries avoid negative laparotomies

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Imaging Options

• Ultrasound
• DPL
• CT Scan
• Wound exploration in stab wounds

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High velocity missile injuries

• Majority of war injuries GSW, IED, Grenade /
  shell wounds
• Injury to both hollow and solid organ
• Multi organ involvement common
• Surgery required in most cases

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Stab wounds (non-ballistic penetrating trauma)

• Most occur in upper
• quadrants
• Injuries dependent on
• Instrument used
• Patient motion
• Parietal peritoneum penetrated in 70
• Only 50 of these (35 total) cause visceral
  injury

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Management

• Less devastating hence time available
• Decision whether to operate or not
• Aim to avoid non therapeutic laparotomy

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Indications of surgery

• Haemodynamic instability
• Peritoneal signs
• Evisceration
• Presence of blood in urinary cathetor, NG Tube or
  in rectum
• Investigate further equivocal signs

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Do Not

• Probe wounds to confirm penetration painful,
  inaccurate
• Wound exploration under local / GA
• No role of stabogram

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Investigations

• Ultra sound
• DPL
• CT
• Laparoscopy

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Laparotomy

• Midline
• Control Haemorrhage
• Control intestinal spillage primary repair or
  exteriorisation
• Wash drain well

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Remember

• Damage Control Surgery
• Abdominal hypertension

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Concept

• US Navy capacity of a ship to absorb damage and
  maintain mission integrity
• Exsanguinating injury sum total of the
  maneuvers necessary to ensure patient survival,
  above all else

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Damage Control Surgery

• Why?
• When?
• How?
• Can we apply it in the services!!

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Why

• Evolved over last two decades
• Advances in pre hospital care
• Changing nature of injuries high velocity
  missiles
• Conventional trauma care definitive control
  repair of all injuries

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1980s 1990s NUMEROUS STUDIES SHOWED THAT
EFFORTS TO PROCEED WITH DEFENITIVE REPAIR LEAD
TO PATIENTS DEMISE DESPITE ADEQUATE CONTROL OF
INTRACAVITARY BLEEDING
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WHY DID PATIENTS WITH ADEQUATE CONTROL OF
INTRACAVITATY BLEEDING DIE?
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Acidosis
Triangle of death
Coagulopathy
Hypothermia
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PREVENTING AND REVERSING THE TRIANGLE OF DEATH
DAMAGE CONTROL Original series reported by Stone
et al found that only 7 of trauma patients who
were cold, coagulopathic and acidotic survived a
full operation 65 survived when the surgery was
aborted and reversal maneuvers were instituted
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How

• Damage Control 3 phased approach
• Primary surgery Haemorrhage control
• Correction of metabolic disorders hypothermia
  in SICU
• Planned Reoperation

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Control of haemorrhage

• Repair or ligation of vessels
• Shunting, not ligation of critical vessels such
  as SMA, RA, Common Iliac artery

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Control of contamination
Clamping
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Tape to prevent contamination
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STAPLING WITH OR WITHOUT ANASTOMOSIS
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Temporary abdominal closure

• Abdominal Hypertension due to
• Intestinal oedema due to massive transfusion
• Ongoing bleeding
• Intra abdominal packing
• Fascial closure under tension
• Prolonged ileus

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Abdominal Hypertension Closure

• gt25 cm of H2O, significant
• Options
• Towel clip skin closure
• Silo bag (Bogota)
• Vacuum closure
• Octreotide to diminish reperfusion injury

Mesh Closure
Bogota Bag
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Temporary Abdominal Closure
Whitman Technique
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Innovations
1
3
2
4
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Phase II - Rewarming

• Starts at Ground Zero
• Keep patient covered
• Cas room/OT temperature 30C
• Radiant Heater, warm blanket

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Correction of hypothermia

• Warm saline lavage intercostal tubes
• Extra corporeal
• Continous arterio venous rewarming
• Warm ventilatory circuits, infusions

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Correction of coagulopathy

• Unless core temp exceeds 35 C normal coagulation
  will not occur
• Laboratory tests are done at 37 C
• TEG information about fibrinolytic activity
  platelet function
• Correction by use of platelets FFP

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Planned Re-exploration

• After correction of triad
• Preferably within 48 h
• Restoration of GI continuity
• Debridement of solid organs
• Colostomy Enteral feeding tubes
• Tertiary survey ( 17 missed injuries)
• Abdominal wall closure

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Dream Team
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Damage control surgery is not a defeat in a
battle or a failure on the part of the surgeon,
but is like retreating to fight another day in
order to win the war which is saving the life of
the patient
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• Thank You