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BLUNT ABDOMINAL TRAUMA

BLUNT ABDOMINAL TRAUMA. By JENISH JOY 2002 MBBS. Background. BAT is a frequent cause of preventable death. Identification of serious intra-abdominal pathology is often challenging. CAUSES. motor vehicle accidents Automobile pedestrian accidents Falls Industrial or recreational accidents

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BLUNT ABDOMINAL TRAUMA

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  1. BLUNT ABDOMINAL TRAUMA By JENISH JOY 2002 MBBS

  2. Background • BAT is a frequent cause of preventable death. • Identification of serious intra-abdominal pathology is often challenging.

  3. CAUSES • motor vehicle accidents • Automobile pedestrian accidents • Falls • Industrial or recreational accidents • Blow to abdomen

  4. Pathophysiology • due to combination of crushing, deforming, stretching and shearing forces.

  5. Approach primary survey • Initial evaluation and resuscitation secondary survey tertiary survey • Diagnostic adjuncts -DPL -Plain radiographs-spine,chest,pelvis -USG -CT scan -Angiography -Diagnostic laparoscopy etc.

  6. INSPECTION • ABDOMINAL BREATHING. • BRADYCARDIA. • CULLENS SIGN & FLANK BRUISING.

  7. PALPATION • MASS, TENDERNESS & DEFORMITIES • FULLNESS & DOUGHY CONSISTENCY • CREPITATION OR INSTABILITY OF LOWER THORACIC CAGE. • INVOLANTRY GAURDING & RIGIDITY.

  8. HEAMOGLOBIN. BLOOD GROUPING. PLATLET COUNT. TC DC. OTHERS LFT, SERUM AMYLASE, URINALYSIS, URINE PREGNANCY TEST, ABG. LAB DIAGNOSIS

  9. Imaging Studies • USG, • FAST, • CT, • DIAGNOSTIC LAPROSCOPY & • ANGIOGRAPHY.

  10. USG Abdomen • Used for detecting - hemo/pneumoperitoneum - solid organ injury/ hematoma • Advantages • noninvasive • Portable • Cheap • No risk of radiation • Can be repeated • Helpful in unstable patients

  11. Disadvantages • Low sensitivity for hollow viscus perf. • Operator dependant • Compromised by presence of lower rib #, soft tissue injuries, dressing, obesity and gas interposition. • Low sensitivity if fluid <500ml.

  12. FAST • Indications • Deteriorating vitals • Four areas scanned • Right upper quadrant • Sub xiphoid area • Left upper quadrant • pelvis

  13. Abdomen CT • Patients suitable – delayed presentations(>12hrs) with stable vitals and no signs of peritonitis, -DPL equivocal with phy. exam unreliable. -DPL difficult to perform -pts with high risk for retroperitoneal injuries • Assessing extent of injury for determining expectant management.

  14. Contra Indication • Clear indication for laparotomy • Unstable vitals, agitated patients. • Allergy to contrast Drawbacks • Radiologist dependant • Expensive, nonportable &time consuming • Can miss hollow viscus perforation • Need for contrast • Cannot detect blunt pancr. injuries in the first 6 hrs.

  15. Diagnostic Laparoscopy • Expensive, invasive • Adv over CT- detect missed small bowel, splenic, retroperitoneal, diaphragmatic injuries, etc. Angiography • Detecting hepatic/splenic vascular injuries managed with embolisation • Detecting renal artery thrombosis • Source of hemorrhage in pts with pelvic#, etc

  16. :Overt peritonitis • :Massive Hemoperitoneum Positive Observe Negative Equivocal Yes High Energy Transfer No No Major solid organ (Grade>III) Stable Yes Hollow Viscus Equivocal Delayed Presentation (>12 hrs) Minor Solid Organ (Grade I, II) Observe Normal Examination

  17. Frequency of organ injuries in BAT

  18. SPLEEN • COMMONEST ORGAN INJURED Clinical features • Left upper quadrant pain • Pain in left shoulder(kehr’s sign) • Fixed dullness in left upp quad(Ballance’s sign) • Palpable mass • Signs of blood loss

  19. INVESTIGATIONS • HEMATOCRIT • LEUCOCYTOSIS • PLAIN XRAY • fracture of lower ribs, • elevation of the left hemidiaphragm • medial displacement of gastric bubble • loss of splenic outline…

  20. CT SCAN IS THE MAIN STAY OF DIAGNOSIS -show blood around spleen -show active bleeding sites

  21. GRADING… • GRADE 1 subcapsular hematoma <10% surface area, capsular tear <1cm parenchymal depth

  22. Grading…. • GRADE 2 subcapsular haem 10-50% surface area. intraparenchymal haem <5cm in diam,laceration extending 1-3cm into parenchyma

  23. Grading… • GRADE 3 subcapsular hematoma >50% surface area intraparenchymal hematoma >=5cm or expanding laceration >3cm into paenchyma

  24. Grading… • GRADE 4 ruptured intraparenchymal hematoma with active bleeding laceration involving hilar vessel

  25. Grading.. • GRADE 5 completely shattered, devascularised spleen

  26. MANAGEMENT • Non operative • Operative • Splenoraphy • splenectomy

  27. SPLENECTOMY • INDICATIONS -Hemodynamically unstable patient -Multiple abdominal injuries -Injury at hilum of spleen -Shattered spleen -Failure of spleenoraphy

  28. BLUNT HEPATIC TRAUMA • size &location • Spont. Hemostasis in >50% cases

  29. GRADING… • GRADE 1 Subcapsular hematoma <10% SA Laceration-capsular tear, <1cm parenchymal depth

  30. GRADING… • GRADE 2 Hematoma-subcapsular 10-50% or intra paranchymal < 10 cm. Laceration-1-3cm parenchymal depth <10 cm length

  31. GRADING… • GRADE 3 Hematoma subcapsular >50% SA or expanding subcapsular or parenchymal hematoma. Intra parenchymal hematoma >10cm or expanding. laceration>3 cm depth.

  32. Grading… • GRADE 4 laceration involving 25-75% hepatic lobe or 1-3 segments

  33. Grading… • GRADE 5 Laceration –hepatic disruption involving >75% of hepatic lobe or morethan three segments of single lobe. Juxta hepatic venus injuries i.e. retro hepatic venacava or central major hepatic veins.

  34. Grading… • GRADE 6 Hepatic avulsion

  35. Surgical Management • Principles of surgical management --control of bleeding --removal of devitalised tissue -- establishment of adequate drainage • Small subcapsulart hematomas without parenchymal injury-observation • Small non deep lacerations controlled with simple sutures or hemostatic agents • Bleeding continuing despite local controltractotomy • Packing with gouze and exploration after 48 hrs • Bleeding still continuing despite ligating the small vessels, pringle’s manouevre

  36. Post operative complications Pulmonary complications Post Op Bleeding and coagulopathy Intra abdominal abscess Biliary fistula Hemobilia Hypoglycaemia Jaundice

  37. GI TRACT STOMACH • Rarely injured as it is • Mobile • Protected by position

  38. Duodenum • Difficult to diagnose because • Second part is usually injured • Retroperitoneal position • Peritoneal signs absent • Bacterial count of duodenum is low • Any blow to upper abdomen suspect duodenal injury

  39. Clinical signs • Testicular pains • Pain referred to shoulders, chest & back • Gastric outlet obstruction

  40. X ray abdomen • Retroperitoneal air • Accumulation of air around right kidney • Obliteration of psoas on right side • Lumbar spine scoliosis to right • Air in front of L1 in lateral view • Coiled spring appearance in intramural haematoma. • CTwith i.v.&ingested contrast-diagnostic

  41. management • Extensive Kocher’s maneuver • Intramural haematoma-conservative • Debridement and suturing • End- to-end anastomosis,serosal patch and Roux-en-Y duodenojejunostomy.

  42. RETROPERITONEAL HEMATOMA • RETROPERITONEAL ZONES • ZONE 1 • ZONE 2 • ZONE 3

  43. ZONE 1 (MIDLINE RETROPERITONEUM) • Extends from diaphragmatic hiatus to sacral promontory • Contents- • Aorta • vena cava • duodenum • pancreas

  44. ZONE 2 (PERINEPHRIC SPACE) • Both abdominal flanks • Contents -kidney ureters colon

  45. ZONE 3(PELVIC RETROPERITONEUM) • Confined to pelvis • Contents-rectum bladder ureter iliac vessels

  46. Clinical features • Abdominal tenderness • flank mass • grey turner’s sign • Cullen’s sign

  47. APPROACH INZONE 1 (central hematoma) • ALL CENTRAL HEMATOMAS MUSTBEEXPLORED WHY??? Due to major abdominal vascular injury

  48. ZONE 2 (lateral hematomas) • Associated with injuries to genitourinary tract • KIDNEY is the • MOST COMMONLY • INJURED organ • Colon injuries

  49. MANAGEMENT • Conservative??? • Hematoma not expanding • IVU or CT SCAN normal • exploration??? • Hematoma is adjacent to colon,concealing an occult colonic injury • Expanding hematoma • Major renal injury

  50. Zone 3 (pelvic retroperitoneal hematoma) • PELVIC FRACTURE IS MOST OFTEN PRESENT AND IS THE MAJOR CAUSE OF RETROPERITONEAL HEMATOMA

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