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ABDOMINAL TRAUMA By Dr. Saleh M.Al-Salamah B.Sc, MBBS, FRCS Associate Professor of Surgery General & Laparoscopic Surgeon College of Medicine King Saud University Riyadh K.S.A

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? Objectives ? Types of abdominal Trauma ? Anatomical regions of the abdomen ? Hospital Care and diagnosis (Evaluation of patient with blunt / Penetarating Trauma) ? Specific organs trauma

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Upon completion of this topic the student will be able to identify the differences in patterns of abdominal trauma based on mechanism. Specifically the student will be able to: OBJECTIVES:

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Describe the anatomical regions of the abdomen. Discuss the difference in injury pattern between blunt and penetrating trauma.

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Identify the signs suggesting retroperitoneal, intraperitoneal or pelvic injuries. Outline the diagnostic & therapeutic procedures specific to abdominal trauma.

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The majority of abdominal injuries are due to blunt abdominal trauma secondary to high speed automobile accidents. The failure to manage the abdominal injuries accounts for majority of preventable death following multiple injuries.

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? The primary management of abdominal trauma is determination that an intra abdominal injury EXISTS and operative intervention is required.

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Types of the abdominal trauma. Blunt abdominal trauma. Penetrating abdominal trauma.

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The recognition of the mechanism of the injury weather is penetrating or non-penetrating trauma is a greatest importance for treatment and diagnosis and workup therapy. The liver, spleen and kidneys commonly involved in the blunt abdominal injuries.

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Anatomical regions of the abdomen: (a) Peritoneum. ? Intrathoracic abdomen ? True abdomen (b) Retroperitoneum abdomen (c) Pelvic abdomen.

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Hospital Care and Diagnosis (Evaluation of patient with Blunt / Penetrating Trauma) ? Initial Management:

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? The resuscitation & Management priorities of patient with major abdominal trauma are. The (ABCDE) of EMERGENCY resuscitations airway, breathing and circulation with hemorrhage control should be initiated. ? NGT & Folly's Catheter.

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HISTORY: (a) Blunt abdominal trauma (b) Penetrating abdominal trauma. PHYSICAL EXAMINATION: ? General physical Examination ? Examination of the abdomen.

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? Inspection ? Palpation ? Percussion ? Auscultation ? Rectal Examination ? Vaginal Examination

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DIAGNOSTIC PROCEDURES (Investigations) (A) Blood Tests (B) Radiological Studies (Plain abdominal X-ray, CXR) (C) Peritoneal lavage (DPL) (D) USS abdomen (E) CT abdomen (F) Peritoneoscopy (Diagnostic laproscopy)

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ESTABLISHING PRIORITIES AND INDICATIONS FOR SURGERY: (The indications for laparotomy) (A) Signs of peritoneal injury (B) Unexplained shock (C) Evisceration of viscus (D) Positive diagnostic (DPL) (E) Determination of finding during routine follow up

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Specific Organs Trauma: ? Liver ? Spleen

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INCIDENCE ? The liver is the largest organ in the abdominal cavity and continues to be the most commonly injured organs in all patients with abdominal Trauma (Blunt/Penetrating) (35-45%) in blunt abdominal Trauma 40% in stab wound 30% in gunshot wounds to abdomen.

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MECHANISM OF INJURY Hepatic injuries result from direct blows, compression between the lower ribs on right side and the spine or shearing at fixed points secondary to deceleration. Any penetrating gunshot, stab or shotgun wound below the right nipple on right upper quadrant of the abdomen is also likely to cause a hepatic injury.

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DIAGNOSIS (LIVER TRAUMA) ? CLINICAL MANIFESTATIONS Diagnosis of hepatic injury is often made at laparotomy in patients presenting with penetrating injuries requiring immediate Surgery Or those sustaining blunt Trauma who remain in shock or present with abdominal rigidity.

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? INVESTIGATIONS: Adjuvant diagnostic tests are necessary in the decision making process to determine whether or not laparotomy is necessary:

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(a) Diagnostic peritoneal lavage (DPL) has been extremely reliable 98% in determining the presence of blood in the peritoneal cavity once (positive) patient should be taken to the Operating Room without delay.

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(b) CT.Scan abdomen used for diagnosing intraperitoneal injuries in stable patients after blunt trauma.

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Patients sustaining significant Right lower thoracic, Right upper quadrant and Epigastric blunt trauma, should be suspected of having suffered a hepatic injury, clinical assessment and abdominal paracentesis SUMMARY Cont ….

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& DPL are most important factors in determining operative intervention. CT Scanning may be useful adjuvant in the haemodynamically stable blunt trauma patient.

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? TREATMENT: When patient arrived to ER the initial management of the patient should be uniform regardless of organs system injuries. Resuscitation is performed (ABCDE) in the standard fashion.

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Non operative approach: The hepatic injury diagnosed by CT in stable patient is now non operative approach practiced in many centers. CT. Criteria for nonoperative management include the following:

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? Simple hepatic laceration Or intrahepatic hematoma ? No evidence of active bleeding ? Intra peritoneal blood loss >250 ml ? Absence of other Intraperitoneal injuries required surgery

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OPERATIVE APPROACH Persistent hypotension, despite adequate volume replacement, suggests ongoing blood loss and mandates immediate operative intervention. Injury classification: This classification based on operative findings and management. So hepatic injury classified as follows:

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? Grade I: Simple injuries – non bleeding ? Grade II: Simple injuries managed by superficial suture alone ? Grade III: Major intraparenchymal injury with active bleeding but not requiring inflow occlusion (Pringle maneuver) to control haemorrhage

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? Grade IV: Extensive intraparenchymal injury with major active bleeding requiring inflow occlusion for hemostatic control ? Grade V: Juxtahepatic venous injury (injuries to retrohepatic cava or main hepatic veins)

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All patients undergoing laparotomy for trauma should be explored through midline incision. OPERATIVE MANAGEMENT:

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?Grade-I&II: Simple injuries can be management by any one of variety of methods (simple suture, electrocautery or Tropical Hemostatic Agents) This type of injury like Liver Bx. does not require drainage. MANAGEMENT OF SPECIFIC LIVER INJURIES:

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Grade III: Major intraparenchymal injuries with active bleeding can best be managed by Finger Fracturing the hepatic parenchyma and ligating or repairing lacerated blood vessels & bile ducts under direct vision. GradeIV: Extensive intraparenchynal injuries with major rapid blood loss require occlusion of portal trial to control haemorrhage.

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SUMMARY Simple techniques includes drainage only of non-bleeding injuries, application of fibrin glue, and sutures hepatorrhaphy and , Application of Surgical (I & II). Advanced Techniques of Repair (III & IV) all performed with Pringle Maneuver in place.

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(a) Extensive hepatorrhaply (b) Hepatotomy with selective vascular ligation (c) Omertal Pack (d) Resectional debridement with selective vascular ligation (e) Resection (f) Selective Hepatic Artery Ligation (g) Perihepatic packing

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COMPLICATIONS & MORTALITY: ? Recurrent bleeding ? Hematobilia ? Perihepatic abscess ? Billiary Fistula ? Intrahepatic Haematoma ? Pulmonary Complications ? Coagulopathy ? Hypoglycemia

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INCIDENCE ? The spleen remains the most commonly injured organ in patients who have suffered blunt abdominal trauma and is involved frequently in penetrating wounds of the left lower chest and upper abdomen. Management of the injured spleen has changed radically over the pastdecade.

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Now recognized as an important immunologic factory as well as reticuloenlothelial filter. Although the risk of over whelming postsplenctomy sepsis (OPSS) is greatest in child less than 2 yrs recognition of OPSS has stimulated efforts to (Conserve spleen) by splenorrhaphy.

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MECHANISM OF INJURY The spleen is commonly injured in patients with blunt abdominal trauma because of its mobility. Most civilian stab wounds and gunshot wounds cause simple lacerations or through and through injuries. It is of interest 2% of patient who are undergoing surgery LUQ of the abdomen can injured the spleen

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PATHOPHYSIOLOGY & CLASSIFICATION The Magnitude of spleanic disruption depend on patient age, injury mechanism and presence of underlying disease spleanic injury have been classified according to their pathologic anatomy as such:

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? Grade I: Subcapsular hematoma ? Grade II: Sub segmental parenchgmal injury ? Grade III: Segmental devitalization ? Grade IV: Polar disruption ? Grade V: Shattered or devascularized organ

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DIAGNOSIS (EVALUATION) Patient History Physical Examination Radiological Evaluation ? CXR ? Plain abdominal X-Ray ? CT Scan ? Angiography

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TREATMENT: Initial Management (Resuscitation) ABCDE ? Non operative approach: ? Widely practiced in pediatric trauma the criteria for nonoperative approach ? Haemodynamically stable children / adult ? Those patient without peritoneal finding at anytime ? Those who did not require greater than two unit of blood

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? Contra indication for splenic salvage: ? The patient has protracted hypotension ? Undue delay is anticipated in attempting repair the spleen ? The patient has other severe injury

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Operative approach: ? Decision to perform splenctomy or splenorraphy is usually made after assessment & grading the splenic injury

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Postsplectomy and splenorraphy complications: ? Early ? Bleeding ? Acute gastric distention ? Gastric necrosis ? Recurrent splenic bed bleeding ? Pancreatits ? Subpherinic abscess

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Late Complications: ? Thrombocytosis ? OPSS (1 – 6 Week) ? DVT

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