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Colonic trauma

Colonic trauma. SR Brown Colorectal Surgeon Sheffield Teaching Hospitals. Types of trauma. Penetrating trauma Gunshots Energy transfer proportional to velocity Cavitation Injury away from track Contamination sucked in Stab wounds Low level energy transfer Injury confined to track.

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Colonic trauma

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  1. Colonic trauma SR Brown Colorectal Surgeon Sheffield Teaching Hospitals

  2. Types of trauma • Penetrating trauma • Gunshots • Energy transfer proportional to velocity • Cavitation • Injury away from track • Contamination sucked in • Stab wounds • Low level energy transfer • Injury confined to track

  3. Blunt trauma • Mechanisms for damage • Crushing • Shearing • Bursting • Penetrating

  4. Evaluation of abdominal penetrating trauma • Haemodynamically unstable • Laparotomy • Haemodynamically stable • Serial clinical exam • Local wound exploration • DPL • FAST • CT • Laparoscopy • Laparotomy

  5. DPL • Positive if • >10ml frank blood • RCC>100,000/mm3 • WCC>500/mm3 • Amylase>20 IU/L • Presence bacteria/bowel contents

  6. Adjuncts to evaluation • CXR • NG tube • Catheter • PR

  7. Pros/cons • Awake/cooperative patient • Invasive • Admission • Retroperitoneum • High clinical workload • Complications

  8. CT features of penetrating abdominal injury • Signs of peritoneal violation • Free air/fluid • Track • Signs of bowel injury • Thickening/defect • Contrast leak • Others • Intravenous contrast leak • Diaphragm tear

  9. Evaluation of blunt abdominal trauma • Haemodynamically unstable • DPL/FAST/CT • Haemodynamically stable • Serial examination • FAST • CT

  10. Surgery for abdominal trauma

  11. Advantages of primary repair • Reduced morbidity of colostomy closure • Reduced disability of colostomy • Reduced hospital stay

  12. Colonic surgery; primary repair

  13. Colonic injury; primary repair in destructive injury

  14. Risk factors for primary repair • Haemodynamicaly unstable • Significant underlying disease • Associated injuries • Peritonitis

  15. Damage control surgery • ‘Multiple trauma patients are more likely to die from intra-operative metabolic failure than a failure to complete operative repairs’

  16. Pathophysiology • Hypothermia • Acidosis • Coagulopathy

  17. Principles of surgery • Control haemorrhage • Prevent contamination • Avoid further injury

  18. Principles of colonic surgery • Repair small enterotomies • Extensive damage resect and close off ends • No stomas • Time consuming • Spillage difficult to control

  19. Abdominal compartment syndrome • Pressure >25cm water • Oedema • Reperfusion injury • Crystalloid infusion • Capillary leakage • Packing

  20. Pathophysiology • Cardiovascular • Decrease cardiac output despite high CVP • Respiratory • Splint diaphragm • Renal • Oliguria due to renal vein/parenchyma compression • Cerebral • Increased CVP results in decreased cerebral drainage

  21. Diagnosis • Oliguria + increasing CVP • Foley catheter in bladder • Normal 0 cm water • >25cm water suggestive • >30cm water diagnostic

  22. Treatment • Anticipate • Difficulty closing • Horizontal view, guts above level of wall • Laparostomy • Bogota bag • VAC dressing

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