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Case History. 52 y.o. male in high speed MVCED / Radiographic findings:Grade III Liver LacerationGrade IV Spleen lacerationOpen book pelvis fracture. Emergent Interventions. External FixatorDamage Control LaparotomySplenectomySuture hepatorrhaphy
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1. Trauma Patient with Open abdomen Courtesy of:
Michael Cheatham, MD
WSACS website
3. Emergent Interventions External Fixator
Damage Control Laparotomy
Splenectomy
Suture hepatorrhaphy
Open Abdomen dressing with vacuum style temporary closure
4. Initial ICU Evaluation MAP=76 HR=124 T=34.5 C
IAP=14 APP=62 (APP=MAP-IAP)
Lactate 3.2
Coagulopathic, Low Plts, Anemic
Abdominal dressing soft, draining serosanginous fluid
5. What should be done? Warm the patient
Transfuse with appropriate blood products
6. 6 hour ICU Evaluation MAP=70 HR=114 T=36.5 C
IAP=24 APP=46 (APP=MAP-IAP)
Lactate 6.5
UOP < 30 cc/ hour, PIP = 60 cm H2O
Abdominal dressing firm and bulging
7. What is wrong? Recurrent Abdominal compartment syndrome
Definition: The redevelopment of ACS following previous surgical or medical treatment to prevent or treat ACS.
The is no such thing as an open abdomen outside the O.R. just an expanded abdomen with temporary abdominal closure.
8. Treatment 6 hours into ICU Vacuum pack is removed
Dramatic bowel evisceration
Replaced with plastic silo dressing
9. Post-dressing expansion MAP=70 HR=96 T=36.7 C
IAP=12 APP=58 (APP=MAP-IAP)
UOP >100 cc/ hour
PIP = 30 cm H2O
10. 24 hours into ICU stay Worsened bowel edema
However:
MAP = 79
IAP = 12
APP = 67
Lactate = 1.9
11. Remaining ICU course Day 2-4: Visceral edema decreases
IAP drops further, VSS remain stable
Day 7: Abdomen is closed primarily
Day 8: Transfer to floor
12. Case points Recurrent ACS:
There is no such thing as an open abdomen
Just an expanded abdomen that is re-dressed
Open abdominal management = High risk of capillary leak and recurrent ACS
All patients who require open abdomens require mandatory serial abdominal pressures to allow early detection of recurrent ACS.