ABDOMINAL TRAUMA

Oleh: Yohni Wahyu Finansah, dr. Pembimbing : Luciana, dr.

DEFINITION
Trauma, or injury, is defined as cellular disruption caused by an exchange with environmental energy that is beyond the body's resilience.

EXTERNAL Anterior Superior : transnipple line Inferior : inguinal ligaments and symphysis pubis Lateral : anterior axillary lines. Flank between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest. Back This is the area located posterior to the posterior axillary lines from the tip of the scapulae to the iliaccrests.

ANATOMY

ANATOMY
INTERNAL Peritoneal Cavity
The upper peritoneal cavity : diaphragm, liver, spleen, stomach, and transverse colon. The lower peritoneal cavity : small bowel, parts of the ascending and descending colon, sigmoid colon, and, in women, internal reproductive organs.
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ANATOMY
INTERNAL Pelvic Cavity : rectum, bladder, iliac vessels, and, in women, internal reproductive organs. Retroperitoneal Space : abdominal aorta, inferior vena cava, most of the duodenum, the pancreas, kidneys and ureters, and the posterior aspects of the ascending and descending colon, and the retroperitoneal components of the pelvic cavity.
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CLASSIFICATION
Based on the mechanism of injury : Blunt Abdominal Trauma
compression crushing or shearing injury deceleration injury

Penetrating Abdominal Trauma

stab wounds gunshot wounds
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Blunt Abdominal Trauma

Penetrating Abdominal Trauma : Stab Wound

Abdominal Evisceration

Penetrating Abdominal Trauma : Gunshot Wound

Gunshot Wound (machine gun)

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INITIAL ASSESMENT & MANAGEMENT

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Primary Survey

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Adjuncts to Primary Survey

Secondary Survey

Adjuncts to Secondary Survey

Monitoring : Vital sign, ECG,CVP NG tube placement Foley catheter placement DPL, FAST Radiograph Laboratory examination History : Allergies Medication Past illnesses or pregnancy Last meal Event related to the injury Mechanism of injury Physical Examination Spesific diagnostic examination : x-rays, CT scans, urography, angiography, USG, bronchoscopy, esophagoscopy,and etc

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SHOCK
A state of inadequate tissue perfusion in which the delivery of oxygen to tissues and cells is insufficient to maintain normal aerobic metabolism. Hemorrhagic shock Cardiogenic shock :
cardiac tamponade, tension pneumothorax, or cardiac injury/insufficiency

Neurogenic shock (spinal cord injury), and Septic shock

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HEMORRHAGIC SHOCK (1)

The goal of fluid resuscitation is to re-establish tissue perfusion. Fluid resuscitation begins with a 2 L (adult) or 20 mL/kg (child) IV bolus of isotonic crystalloid, typically Ringer's lactate. For persistent hypotension, this is repeated once in an adult and twice in a child before red blood cells (RBCs) are administered
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HEMORRHAGIC SHOCK (2)

Good response to fluid infusion :
normalization of vital signs, clearing of the sensorium and evidence of good peripheral perfusion : warm fingers and toes with normal capillary refill)

Urine output is a quantitative reliable indicator of organ perfusion. Adequate urine output is 0.5 mL/kg per hour in an adult, 1 mL/kg per hour in a child, and 2 mL/kg per hour in an infant <1 year of age.
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INITIAL MANAGEMENT
Begins with :
the rapid restoration of cardiopulmonary function the prioritized management of airway, breathing, and circulation

Two most important diagnostic and therapeutic goals:

Rapid identification and control of major hemorrhage Identification and treatment of traumatic brain injury (TBI)
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HISTORY
Blunt Trauma (1) Assessing the patient injured in a motor vehicular crash includes : speed of the vehicle, type of collision (frontal impact, lateral impact, sideswipe, rear impact, and rollover), vehicle intrusion into the passenger compartment, types of restraints, deployment of an air bag, the patients position in the vehicle, and status of passengers
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HISTORY
Blunt Trauma (2)

This information can be provided by : the patient, other passengers, the police, or emergency medical personnel. Information about: vital signs, obvious injuries, and response to prehospital treatment
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HISTORY
Penetrating Trauma

historical information to obtain includes : the time of injury, type of weapon (knife, handgun, rifle, shotgun), distance from the assailant (important with shotgun wounds, as the likelihood of major visceral injuries decreases beyond the 10-foot or 3-meterrange), number of stab wounds or shots sustained, and the amount of external bleeding from the patient noted at the scene.
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PHYSICAL EXAMINATION
NO

FIND
Inspection

1.

abrasions, contusions from restraint devices, lacerations, penetrating wounds,impaled foreign bodies, evisceration of omentum or small bowel, and the pregnant state confirm the presence or absence of bowel sounds signs of peritonitis, tympanitic sounds over an acute gastric dilatation in the left upper quadrant or diffuse dullness when a hemoperitoneum is present 24

2.

Auscultation

3.

Percussion

PHYSICAL EXAMINATION
NO

FIND
Palpation

4.

to elicit and localize superficial (often abdominal wall), deep, or rebound tenderness. The presence of a pregnant uterus, as well as estimation of fetal age, also can be determined
Gunshot wounds 90% intraperitoneal injury laparotomy Stab wounds 30% intraperitoneal injury laparotomy any hemodynamically abnormal signs of peritonitis or mandates immediate abdominal distention laporotomy

5.

Evaluation Penetrating Trauma

6.

Assessing Pelvic Stability

abnormal movement or bony pain, which suggests a pelvic fracture in patients who sustain blunt truncal trauma. this maneuver may cause or aggravate bleeding. 25

PHYSICAL EXAMINATION
NO

FIND Penile, perineal, and rectal examination

7.

8. 9.

Vaginal Examination Gluteal Examination

the urethral meatus : blood a urethral tear scrotum and perineum : ecchymoses or a hematoma rectal examination : Blunt : assess sphincter tone, the position of the prostate (high-riding prostate indicates urethral disruption), and to determine whether fractures of the pelvic bones are present. Penetrating : assess sphincter tone and look for gross blood from a bowel perforation. Laceration of the vagina Penetrating injuries to this area up to a 50% incidence of intraabdominal injuries.
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INSERTION GASTRIC TUBE

to relieve acute gastric dilatation, decompress the stomach before performing a DPL, and remove gastric contents, thereby reducing the risk of aspiration Blood (+) in the gastric secretions an injury to the esophagus or upper gastrointestinal tract if nasopharyngeal and/or oropharyngeal sources are excluded.
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INSERTION URINARY CATHETER

The goals of inserting this tube early in the resuscitation process are :
to relieve retention, decompress the bladder before performing a DPL, and allow for monitoring of the urinary output as an index of tissue perfusion

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BLOOD AND URINE SAMPLING

Blood type and crossmatch Complete blood count (CBC) Electrolyte levels BUN level Creatinine level Glucose level Prothrombin time (PT)/activated partial thromboplastin time (aPTT) Venous or arterial lactate level Calcium, magnesium, and phosphate levels Urinalysis Serum and urine toxicology screen A blood test or urine pregnancy test is indicated in all females of childbearing age.
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BLUNT

X-RAY STUDIES

PENETRATING

Multisystem blunt trauma : lateral cervical spine x-ray, anteroposterior (AP) chest x-ray, pelvic x-ray . Hemodynamically normal : Abdominal x-rays (supine, upright, or lateral decubitus) detect : extraluminal air in the retroperitoneum free air under the diaphragm LAPAROTOMY Retroperitoneal injury loss of a psoas shadow

Hemodynamically abnormal does not require any screening x-rays in the emergency department. Penetrating trauma above the umbilicus/ suspected thoracoabdominal injury an upright chest x-ray to exclude : hemo- or pneumothorax To determine the track of the missile or the presence of retroperitoneal air With marker rings or clips applied to all entrance- and exit-wound sites, a supine abdominal x-ray

Special circumstance contrast studies : urethrography, sistography, CT scan/IVP, gastrointestinal (CT with contrast or specific upper and lower gastrointestinal contrast)
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In the upright position, blood is visible dependently in the pleural space

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DIAGNOSTIC STUDIES IN BLUNT TRAUMA DPL (Diagnostik Peritoneal Lavage) FAST (Focused Assesment Sonography in Trauma) CT (Computed Tomography)

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DPL
Indications for DPL in blunt trauma include: 1. Change in sensoriumBrain injury, alcohol intoxication, and use of illicit drugs 2. Change in sensationInjury to spinal cord 3. Injury to adjacent structuresLower ribs, pelvis, lumbar spine 4. Equivocal physical examination 5. Prolonged loss of contact with patient (anticipatedGeneral anesthesia for extraabdominal injuries, lengthy x-ray studies, eg, angiography (hemodynamically normal or abnormal patient)) 6. Lap-belt sign (abdominal wall contusion) with suspicion of bowel injury 7. DPL also is indicated in hemodynamically normal patients when the same situations are present,but when ultrasound or CT is not available.
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DPL
Absolute contraindication: an existing indication for laparotomy Relative contraindications : previous abdominal operations, morbid obesity, advanced cirrhosis, and preexisting coagulopathy
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DPL

Either an open or closed (Seldinger) infraumbilical technique In patients with pelvic fractures or advanced pregnancy, an open supraumbilical approach is preferred to avoid entering a pelvic hematoma or damaging the enlarged uterus
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DPL
RESULT :
free aspiration of blood, gastrointestinal contents, vegetable fibers,or bile through the lavage catheter hemodynamically abnormal mandates laparotomy

If gross blood (>10 mL) or gastrointestinal contents are not aspirated, lavage is performed with 1000 mL of warmed Ringers lactate solution (10 mL/kg in a child) adequate mixing of peritoneal contents with the lavage fluid sent to the laboratory for quantitative analysis

A positive test is indicated by : >100,000 RBC/mm3, 500 WBC/mm3, or a Gram stain with bacteria present.

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FAST
Purpose is to identify fluid in one of four areas: Morrison's (hepatorenal) pouch in the right upper quadrant The splenorenal recess in the left upper quadrant The pelvis The pericardial sac The indications for the procedure are the same as for DPL Factors that compromise its utility are: obesity, the presence of subcutaneous air, and previousabdominal operations.
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FAST

at least 250 ml of fluid must be present before it can be reliably detected by FAST
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FAST

Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma. CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused abdominal sonography for trauma; Hct = hematocrit.
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CT
Used only in hemodynamically normal patients in whom there is no apparent indication for an emergency laparotomy The CT scan provides information relative to specific organ injury and its extent, and also can diagnose retroperitoneal and pelvic organ injuries that are difficult to assess by a physical examination, FAST, or peritoneal lavage. Relative contraindications to the use of CT include:
delay until the scanner is available, an uncooperative patient who cannot be safely sedated, an allergy to the contrast agent when nonionic contrast is not available.
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Blunt abdominal trauma with liver laceration.

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Blunt abdominal trauma. Right kidney injury with blood in the perirenal space. Injury resulted from a high-speed motor vehicle collision.

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DPL Versus FAST Versus CT in Blunt Abdominal Trauma

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DIAGNOSTIC STUDIES IN PENETRATING TRAUMA

1. Lower chest wounds Diagnostic options in asymptomatic patients with possible injuries to the diaphragm and upper abdominal structures include :
serial physical examinations, serial chest x-rays, thoracoscopy, laparoscopy, or CT (for right thoracoabdominal wounds)

left-sided thoracoabdominal stab wounds immediate surgical exploration left-sided thoracoabdominal gunshot wounds the safest policy is laparotomy
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2. Local wound exploration and serial physical examinations versus DPL in anterior abdominal stab wounds
55-65% hypotension, peritonitis, or evisceration of omentum or small bowel. Emergency laparotomy 50% local wound exploration

Penetrating anterior peritoneum

asimptomatik

serial physical examinations over a 24-hour period, DPL, or diagnostic laparoscopy

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3. Serial physical examinations versus doubleor triple-contrast CT in flank or back injuries

The thickness of the flank and back muscles protects the underlying viscera from injury with many stab wounds or some gunshot wounds to these areaslaparotomy is a reasonable asymptomatic include:
serial physical examinations symptomatik double- or triple-contrast CT, or time consuming & demands full study of the retroperitoneal colon on the side of the wound DPL (+) laparotomy
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DPL
Indications for DPL in penetrating trauma include: patients in whom the need for laparotomy is unclear, tangential wounds in which peritoneal penetration is uncertain, stab wounds in which there are no peritoneal signs or signs of peritoneal penetration, and low chest wounds to identify diaphragmatic injury.
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FAST FAST : (+) laparotomy (- ) cannot rule out the need for laparotomy and cannot be relied on to exclude important intraperitoneal injury

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DEFINITIVE MANAGEMENT

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NON OPERATIVE MANAGEMENT (CONSERVATIVE)

Stable hemodynamic Observation and expectation To prevent negative laparotomy Example : Liver Injury grade I, II, III, and spleen injury grade I, II, III (hemodynamically normal, stop bleeding)

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Algorithm for the assessment of the patient with blunt abdominal trauma

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Decision algorithm for evaluation of penetrating abdominal trauma in the adult

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Algorithm for the management of stab wounds to the abdomen

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ABDOMINAL EXPLORATION FOR PENETRATING TRAUMA

carefully examine the path or potential path of the stab or gunshot wound until : (1) the tract is completely defined and all injuries treated, or (2) the wound tract is found to pass beyond any vital structures, or (3) all structures possibly subject to injury are completely evaluated. This trace-the-track approach coupled with a systematic evaluation of all intraperitoneal and retroperitonealstructures is critical to avoid missed intraabdominal injuries.
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LAPAROTOMY
Acces & Exposure Hemostasis Ressection Reconstruction Damage Control Surgery

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INDICATIONS FOR LAPAROTOMY IN ADULTS (1)

1. Blunt abdominal trauma with hypotension and clinical evidence of intraperitoneal bleeding 2. Blunt abdominal trauma with positive DPL or FAST 3. Hypotension with penetrating abdominal wound 4. Gunshot wounds traversing the peritoneal cavity or visceral/vascular retroperitoneum 5. Evisceration
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INDICATIONS FOR LAPAROTOMY IN ADULTS (2)

6. Bleeding from the stomach, rectum, or genitourinary tract from penetrating trauma 7. Presenting or subsequent peritonitis 8. Free air, retroperitoneal air, or rupture of the hemidiaphragm after blunt trauma 9. Contrast-enhanced CT demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma.
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DAMAGE CONTROL SURGERY (DCS)

Damage control operations/surgery are performed in injured patients with profound hemorrhagic shock and preoperative or intraoperative metabolic sequelae that are known to adversely affect survival prolongation of operative procedures in the setting of major intraabdominalvascular or hepatic injuries and massive transfusion have been associated with:
worsening metabolic acidosis, coagulapathy, hypothermia,
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Intraoperative Indications to Perform DCS

Bleeding 4-5 L
Rescucitation / time operation > 90 menit
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DAMAGE CONTROL SURGERY (DCS)

Patients Likely To Need Damage Control Operations Abdominal or Pelvic Trauma : Penetrating abdominal wound and systolic blood pressure <90 mmHg Blunt abdominal trauma, systolic blood pressure <90 mmHg, and peritoneal fluid on surgeon-performed ultrasound or gross blood on diagnostic peritoneal tap Closed pelvic fracture, systolic blood pressure <90 mmHg, and peritoneal fluid on surgeon-performed ultrasound or gross blood on diagnostic peritoneal tap Open pelvic fracture
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DAMAGE CONTROL SURGERY (DCS)

In damage control mode, definitive control and repair of all injuries are deferred and the operative procedure concluded A variety of techniques have been utilized, including :
hepatic packing, preemptory splenectomy, stapled control of GI laceration (often deferring reanastomosis), ligation of (carefully selected) vascular injuries, and tamponade packing of other areas of dissection or injury.
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Postoperative and Postinjury Complications

1. Missed Injuries 2. Intraabdominal Compartment Syndrome (IACS)
severe intraabdominal injuries, massive fluid resuscitation, high abdominal wall tension, and a variety of adverse physiological sequelae :
decreased urine output, high peak airway pressures, compromised organ perfusion, has led to the description of

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IACS
IACS is produced by excessive intraabdominal pressures as the result of massive bowel edema, third space fluid, intraperitoneal hemorrhage, or retroperitoneal hematomas. decreases in splanchnic, renal, and abdominal wall perfusion and may produce venous capacitance pooling in the pelvis and lower extremities from a tourniquetlike effect on the midtorso
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IACS
Measurement of intravesicular (bladder) pressure, performed by : instilling 50 to 100 ml fluid in the bladder and measuring pressure via Foley catheter using either manometry or a pressure transducer. Pressure readings that are greater than 30 cm H2O are consistent with IAC
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IACS
The treatment of IACS has generally involved Decompression of the abdominal compartment Placement of a temporary abdominal wall prosthesis. In many instances,resolution of abdominal compartment edema allows either single or staged closure of the abdominal wall

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SPECIFIC INJURIES

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DIAPHRAGM
the left hemidiaphragm is more commonly injured. The most common injury is 5 to 10 cm in length and involves the posterolateral left hemidiaphragm. Abnormalities on the initial chest x-ray include :
elevation or blurring of the hemidiaphragm, a hemothorax, an abnormal gas shadow that obscures the hemidiaphragm, or the gastric tube positioned in the chest.

However, the initial chest x-ray may be normal in a small percentage of patients.
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LIVER INJURIES

Principal therapeutic goals Control of hemorrhage, control/containment of biliary drainage. Diagnosis/staging CT staging preferred if possible for blunt injury. Selection for nonoperative management based on clinical behavior & CT findings. DPL or U/S(blunt) if unstable. Packing. Inflow occlusion (Pringle). Hepatic mobilization. Sternotomy extension for exposure. Hepatic isolation (including aortic clamp) or atrial-caval shunt. Simple hepatorraphy. Packing w/planned return to OR. Hepatotomy or wound tractotomy w/oversew of bleeding. R. hepatic artery ligation for selected injuries. Resectional 70 debridement if necessary.

Intraoperative maneuvers (options) for control & access Therapeutic options

SPLENIC INJURIES (1)

Principal therapeutic goals Control of hemorrhage. Preservation of splenic function if possible. Diagnosis/staging Intraoperative maneuvers (options) for control & access Therapeutic options Same as for hepatic injuries. Lower threshold for operative intervention based on CT. Complete mobilization of spleen. Proximal hilar control. Necessary for splenectomy or splenorrhaphy. Splenectomy. Splenorrhaphy: suture, pledgets, wrapping, partial splenectomy.
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SPLENIC INJURIES (2)

nonoperative splenic management should generally meet the following conditions: (1) no evidence of hypovolemic shock, persistent or recurrent splenic hemorrhage, massive hemoperitoneum, or grade V injury; (2) no anticipated need for transfusion requirements as the result of splenic injury; (3) no evidence of active extravasation or splenic vascular injury seen on abdominal CT scan; (4) no other indications for exploratory laparotomy; (5) age less than 50 to 55 years; and (6) no exacerbating factors such as coagulopathy or portal hypertension.
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PANCREATIC INJURIES
Principal therapeutic goals Control of associated hemorrhage. Control of exocrine secretions. Diagnosis/staging CT for diagnosis. (Injuries may be missed by DPL.) Threshold for operative exploration should be low. DPL or U/S if unstable.

Intraoperative maneuvers (options) for control & access

Therapeutic options

Complete exposure of area of suspected injury. Thorough assessment of major pancreatic duct (MPD) injury (inspection, pancreatogram, ERCP).
Drainage only (contusions, minor lacerations). Distal resection (MPD injuries) of body/tail. Drainage w/sphincterotomy vs. resection (Whipple) for major injuries to pancreatic head.

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DUODENAL INJURIES
Principal therapeutic goals Control of associated hemorrhage. Control of GI secretions with reestablishment of duodenal continuity. Maximizing suture line durability. Diagnosis/staging Same as for pancreas. Isolated intramural hematomas may be treated expectantly. Low threshold for operative exploration. DPL or U/S if unstable. DPL for SW. Complete mobilization of duodenum: Kocher ligament of Trietz takedown as needed. Simple repair. Repair w/tube duodenostomy. Jordan modified diversion (see text). Rouxen- Y jejunoduodenostomy for augmentation. Resection for combined pancreatic head injuries only.

Intraoperative maneuvers (options) for control & access Therapeutic options

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COLORECTAL INJURIES
Principal therapeutic goals Reestablishment of GI continuity. Prevention of colon-related septic complications.

Diagnosis/staging Intraoperative maneuvers (options) for control & access

Therapeutic options

CT poor for diagnosis of hollow-viscous injuries. Complete mobilization of involved region of colon. Flexible sigmoidoscopy for rectal evaluation.
Primary repair for most penetrating colon & selected rectal injuries. Diversion repair/ resection reserved for more severe combined injuries (colon) & most rectal injuries.

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Retroperitoneal Hematoma (1)

Zone 1 Zone 2 Zone 3

: central retroperitoneal hematomas : perinephric hematomas : pelvic hematomas

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Retroperitoneal Hematoma (2)

Principal therapeutic goals Control of hemorrhage, avoidance of missed injuries. Diagnosis/staging CT preop. DPL insensitive and nonspecific. Hematomas graded according to location: central, pelvic, perinephric.

Intraoperative maneuvers (options) for control & access

Retroperitoneal exploration indicated for all central hematomas. Exploration indicated for all large, expanding, or pulsatile perinephric hematomas. Pelvic fracture hematomas may be packed if necessary, but should be explored only for suspected major vascular injuries.

Therapeutic options
nerve damage

Repair of associated vascular, pancreatic, or renal injuries. Pelvic fracture hemorrhage controlled by angiography embolization Posterior C-clamp Cx: inferior gluteal artery and sciatic fixation. pelvic external

C Clamp for HAEMATOMA ZONA III (PELVIS)

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SUMMARY
Trauma Abdomen : - Trauma tumpul intra & - Trauma tajam retroperitoneal Memilih modalitas diagnosis yang tepat Pengenalan diri untuk intervensi bedah atau observasi expektatif Intervensi bedah : Laparatomi & Laparatomi DCS
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REFERENCES
1. Advanced Trauma Life Support,Seventh Edition. 2004: American College of Surgeons 2. Essential Practice of Surgery Basic Science and Clinical Evidence. 2003: Springer 3. Schwartz's Principles of Surgery, Ninth Edition. 2010: The McGraw-Hill Companies, Inc 4. Schein's Common Sense Emergency Abdominal Surgery, 2nd Edition. 2005: Springer 5. Trauma, 6th Edition. 2008: The McGraw-Hill Companies, Inc
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