Management of blunt abdominal trauma

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Slide 1 : Management of blunt abdominal trauma Subash Gupta Gyan Burman Liver Surgery Unit Sir Ganga Ram Hospital New Delhi
Slide 2 : Plan ABC of resuscitation ATLS DPL/US /CT scan Damage control surgery Specific issues in surgical care
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Slide 4 : Resuscitation Circulation Two large bore(16G) 2 L Ringer’s lactate Rapid responder: surgical evaluation necessary initially Transient response: ongoing loss/inadequate resuscitation, rapid surgical intervention Minimal or no response, immediate intervention Pump failure, myocardial contusion/tamponade Permissive hypotension, ‘Pop the clot’ not with head injury
Slide 5 : Permissive Hypotension for Trauma Resuscitation Jon Hoerner, trauma.org (7:10) October 2002 Please mark my word. Within no less than 10 years, probably even less than 5 years, any [one] that raises the blood pressure to higher than 3/4 the pre injury level, especially if using crystalloid solutions will be severely criticized as violating one of the indicators, whether the injury be penetrating, blunt, elderly, child, or one's own self or family. Also mark this down on this date. The final target for a prehospital or EC measured BP will be that greater than 80 SYSTOLIC will be the level that the QA moral police will cite that those of you who believe in two large bore IVs, Rapid infusors, interosseous and sternal infursors, the 3 to 1 rule, and cyclic hyper resuscitation as causing unnecessary complications, deaths, and costs. Ken Mattox. Trauma.Org Trauma-List, 30th August 2002
Slide 6 : Abdominal trauma Peritoneal cavity: major occult loss Assessment: accurate diagnosis not important, but recognise that abdominal injury exists Special diagnostic tests Equivocal, unreliable, impractical Diagnostic lavage/CT scan FAST
Slide 7 : Liver Trauma Conservative: paradigm shift Before 1993, routine operative treatment Between 1993 - 1994, selective non operative management Between 1994 - 1998, non operative management standard practice
Slide 8 : Conservative treatment Avoids laparotomy and complications of laparotomy Decreases blood transfusion High success rate: irrespective of CT extent of injury, extent of haemoperitoneum No evidence to suggest missing of other injuries Contrast blush or ongoing haemorrhage indication for embolization
Slide 9 : Liver trauma (contd.) Blunt Gunshot/penetrating: explore Angiogram, bile duct complications Perihepatic packing
Slide 10 : Operative technique Suturing Liver suture Resection ?Mesh compression Inflow occlusion
Slide 11 : Operative technique Exposure and haemostasis Mobilisation Direct pressure, electrocautery, argon beam coagulation, finger fracture with direct ligation of bleeders Pringle manoeuvre, Avoid deep liver sutures Vascularised omental flap for tamponade
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Slide 20 : Pancreas Explore and drain Distal pan/splenectomy Recognise duodenal injury Refer or call for help if needed pancreaticoduodenectomy Whipple’s resection (SGRH, < 5% mortality)
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Slide 25 : Spleen Conservation Key is to be able mobilise spleen outside the incision Delayed rupture ??? Splenic conservation data??
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Slide 30 : Damage Control surgery
Slide 31 : Damage control Control haemorrhage and contamination Resuscitation: correct hypothermia, acidosis and coagulopathy Return to OT: definitive repair Post operative care
Slide 32 : Damage Control Surgery Phase I Rapid termination of operative procedure Arrest of bleeding Removal of contamination Phase II Correction of physiologic abnormalities Acidosis, hypothermia, coagulopathy Phase III Definitive surgery
Slide 33 : What is different? Surgical dogma: complete the operation 1908: Pringle packing of liver injury Fell out of favour, not used in Vietnam war 1981: Feliciano 90% survival by packing in severe liver injury 1983: Stone abbreviated laparotomy, 11/17 survivors Rotundo: damage control surgery, 1990s
Slide 34 : The lethal triad Bleeding coagulopathy Acidosis hypothermia
Slide 35 : Hypothermia Fluids needed for resuscitation Exposure of body Large incision and long duration of procedure Blood loss, decreased O2 consumption and decreased heat production
Slide 36 : Effects of hypothermia 100% mortality if core temp < 32C Diminished cardiac function Coagulopathy: clotting cascade is a temp. dependent reaction, fibrinolysis, platelet dysfunction/sequestration
Slide 37 : Acidosis Lactate production from anaerobic metabolism Failure to normalize lactate concentration by 48 hours, mortality between 86 to 100% Systemic effects: decreased contractility, impaired response to catecholamines and ventricular arrhythmias Coagulopathy worsened
Slide 38 : Coagulopathy Dilution worsens coagulopathy Dilution and hypothermia additive Acidosis worsens coagulopathy
Slide 39 : Damage control procedure ABC Life threatening bleeding: rush to OR Temp elevated, Warm ventilator circuit, Bair hugger, early replacement of coagulation factors No effective guidelines when to initiate damage control
Slide 40 : Abdomen Liver packing Ligation of blood vessels Placement of intraluminal shunts Chest tubes in to aorta or IVC Inflatable balloon catheters
Slide 41 : Abdomen II Resect hollow viscus with stapler Biliopancreatic injuries by closed suction drainage Ligation of ureter or tube ureterostomy Formal closure Abdominal compartment syndrome ARDS MOF Closure of skin, mesh
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Slide 45 : Stage II, resuscitation Similar principles as in OR ? Continuous arteriovenous rewarming Reduces time to normothermia Resuscitation requirements Early mortality Correction of acidosis: Hyperchloremic acidosis versus lactic acidosis, anion gap narrow versus widened Correction of coagulopathy
Slide 46 : Definitive operation Attempt to return to OR within 72 hours Remove packs Complete exploration Haemostasis Small bowel continuity Large bowel exteriorization
Slide 47 : Abdominal compartment syndrome End organ dysfunction secondary to intraabdominal hypertension Tense abdomen, Elevated peak airway pressure Inadequate ventilation Inadequate oxygenation Oliguria Reversed with decompression Bladder pressure >16mmHg Full blown syndrome >35 mmHg Worse with fascial closure
Slide 48 : Control of bleeding Bleeding DU, assistant to compress aorta against spine while taking stitches Leaking aneurysm: mobilise left lobe, loop oesophagus divide crus of diaphragm and control supracoeliac aorta Ligation of internal iliac vessels if there is retroperitoneal bleeding, pelvic trauma
Slide 49 : Summary Important to recognise when to stop operating: stop the bleeding and deal with contamination Discretion is better part of valour Surgery should not be delayed till patient is adequately resusci

 


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