Abdominal Trauma

Abdominal TraumaScott Reed, M.D.

Abdominal TraumaAbdomenDerived from Latin word abdere which means to hideOften referred to as the black box.Follow the clues

Abdominal TraumaCatagorized according to MechanismPenetratingGunshotStabbingsBluntMotor vehicle / Motorcycle accidentsAssaultFallsPedestrians struck

Abdominal TraumaTrauma. Fourth ed. Mattox

Abdominal TraumaTrauma, Fourth ed. Mattox

Abdominal TraumaMajor source of Morbidity and MortalityRapid Diagnosis is KeyAutopsy study comparing two trauma systems100 consecutive deathsSan Francisco County Trauma system where all major injuries went to a Level I trauma centerOrange County Transported to nearest hospitalWest, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A study of two counties. Arch Surg 114:455, 1979

Abdominal TraumaSan Francisco Co.16 deaths 1 considered preventableMissed Thor. Aortic injury

Orange County30 deaths- 22 considered preventable10 of 22 died due to shock from unrecognized abdominal injury8 of 10 died in the first 6 hoursWest, JG, Trunkey, DD, Lim, RC: Systems of Trauma Care: A study of two counties. Arch Surg 114:455, 1979

Abdominal Trauma - DiagnosisPhysical ExamRequires neurologically intact patientPain / TendernessGuardingRebound / Peritoneal signsAll thats needed in penetrating traumaAll thats needed in hemodynamically unstable blunt trauma.

Abdominal Trauma DiagnosisPhysical ExamPenetrating Gunshot wounds (high energy injury)Determining the trajectory can give an idea of what is injuredNeed even number of holes and/or bullets on X-rayMust be careful since bullets can settle to dependent areas

Abdominal Trauma DiagnosisPhysical ExamPenetrating Stabbing (Low energy)More difficult since there is only an entrance and no trajectoryInjury can be far from the injuryMay be all that is needed in hemodynamically stable patients (observation). No good study to pick up hollow viscus injuries.

Abdominal Trauma - DiagnosisUltrasound (F.A.S.T.)Focused Abdominal Sonogram for TraumaReally is fast (done in the trauma bay)Non-invasive and can be repeatedOnly determines the presence of fluid in the abdomen (between 80 95% sensitive)Not very specific (which organ) or what type of fluid (blood, succus, ascites)

Abdominal Trauma X-RaysCan show evidence of free air (hollow viscus injury)Can help determine the trajectory of the missile

41 y/o femaleS/P MVA

Level of the Aortic Arch

Abdominal Trauma - DiagnosisDiagnostic Peritoneal Lavage (DPL)Has all but been replaced by FAST examInserted catheter into abdomenGross blood (10cc or more) - positiveInstilled 1 liter normal salineOver 100,000 RBCs, 500 WBC, bile or fibers of food on micro - positive

Abdominal Trauma - DiagnosisDiagnostic Peritoneal LavageInvasive 1% injury rateOversensitive (small amount of blood can make a positive by micro) 50ccNon-specificProblem in the era of non-operative management of solid organ injury? Role in CT with fluid but no solid organ injury (? Hollow viscus injury)

Abdominal Trauma - DiagnosisComputed Tomography (CT Scan)Started in mid-1980s and has revolutionize trauma care.Sees more than just the abdomen (spinal and pelvic fractures) Done in conjunction with the head and C-spine.More specific (solid organ injury) and examines the retroperitoneal areas (pancreas, kidney, duodenum)Arterial injuries can be studied

Abdominal Trauma - DiagnosisCT Scan DrawbacksMisses hollow viscus injuriesCant evaluate the diaphragmInvolves IV contrast (allergic reactions 1:1000) and radiationTough to run a code in a donut (need a stable patient)

Abdominal Trauma - AngiographyUsing catheters via a femoral / brachial approach to occlude arteriesUsed increasingly for solid organ injuryLiver Embolize either Right/Left hepatic arteries (Liver has both arterial and portal blood supplies)Spleen Can be selective or embolize the entire organ

Abdominal Trauma - AngiographyCan convert what would be a large and bloody case into a easily managed situationDoesnt always workNow operating later on a sicker patientCan embolize too much and infarct other vascular bedsAll fluid isnt blood Can miss small bowel injuries

Abdominal Trauma - ObservationLiver and Spleen injuries can be observedAcceptable in minor injuries with minimal bleeding seen on CT scanHave to observe VERY closelyRepeated abdominal examsVital signs, dropping hematocritsHave to be ready to operate if needed quickly

Abdominal Trauma - DiagnosisLaparoscopyExcellent for stable stab wounds (peritoneal penetration/diaphragm injury)Hard to see everythingCan run the bowel hard to see retroperitoneum, lesser sac, and assess liver / spleen injuriesInvasive, expensive may need to to open

Abdominal Trauma - SurgeryOnce thought that all repairs needed to be done at the initial surgeryLong surgery / multiple repairs on hemodynamically unstable patientsCold, Acidotic, CoagulopathicPatients died

Abdominal Surgery - SurgeryDamage Control surgeryStop the bleeding and contamination and then get out.Pack the liverStaple out injured small bowel/colon (no anastamosis needed)Vascular shunts Leave abd open or just close skinGet to ICU for resuscitation/warming

Abdominal Trauma - SurgeryDamage Control SurgeryAfter 24 to 48 hours go back to the ORPatient is resuscitated, warm, stableEstablish GI continuityWash out areas of contaminationVascular repairsPatients live

Abdominal Trauma - NursingThe Open Abdomen A clear, fenestrated plastic layer over the bowel and viscera (Vi-drape)OR towel, Kerlex, or sponge in the dead spaceLarge drains in the guttersCover entire opening with occlusive dressing (Ioban)Place drains to suction

Abdominal Trauma - NursingOpen Abdomen (VacPack, Blue Towel)Can be done fast in the ORControls abdominal fluids (can measure)Prevents abdominal compartment syndrome (more to follow)Can be taken down in ICU to allow inspection of the abdomen

Abdominal Trauma - NursingDrainsPlaced in areas where fluid may collect.Near an anastomosisPancreatic injuryMust look for changes in output Increase could signal a leak, or sudden stop could indicate the drain is cloggedType and quality of the fluid (suddenly becomes bloody or bilious)

Abdominal Trauma NursingFistulasAbnormal connection between two epithelialized compartments.Named for the two organs connected

Abdominal Trauma - NursingFistulasEnterocutaneous (Small bowel to skin)Most commonUsually involves the wound or incisionWill see bowel contents in the woundOften due to surgical mishaps

Abdominal Trauma - NursingColocutaneous (colon to skin)Colovesicular (colon to bladder)The stomach, pancreas, gallbladder, arteries, and veins can all be involved in fistulas

Abdominal Compartment Syndrome

Mechanism: Direct external pressureon vascular structures, diaphragm and abdominal wall

Abdominal Compartment SyndromeWhat is normal?At rest 0 5mmHgValsalva 60 80mmHgCough80cmH2OVomiting60cmH2OActive liftingOver 150mmHgDuring lifting the pressure is related to the velocity of muscle contraction and comes back to baseline once the movement has ended

Abdominal Compartment SyndromeGrading SystemGrade I10 15mmHgGrade II16 - 25mmHgGrade III26 35mmHgGrade IV>35mmHg

Abdominal Compartment SyndromeCauses (Acute)Intra-abdominalBowel obstruction / IleusRuptured AAAMesenteric venous obstructionAbscessPneumoperitoneumIntraperitoneal bleed / traumaViseral edema RetroperitonealPancreatitisPelvic Frx/bleedsRuptured AAA

Abdominal WallBurn EscharMassive hernia repairClosing the tight abdomen

Abdominal Compartment SyndromeConstellation of SymptomsRenal failureDecreased urine outputRespiratory failureDec compliance, inc pulmonary edema / airway pressureCardiac failureDecreased cardiac output (dec preload / inc afterload)Visceral failureDec blood flow to liver, bowel (bacterial translocation)Neurologic complicationsIncreased intracranial pressureAbdominal wall failure Dehissence, hernia formation

Abdominal Compartment SyndromeTypesPrimaryhypertension (IAH) Secondary A process within or involving the abdomen itself which leads to increased intra-abdominalSecondaryIAH which results even though no direct abdominal injury has occurredOften overlookedStrongly related to resuscitation fluids (iatrogenic)

Saggi et. al Journal of Trauma 1998

Abdominal Compartment SyndromeMeasuring pressuresBladder Pressure (gold standard)Clamp foley catheterInstill 50-100cc saline into bladderUse pressure transducer via sampling portAccurate Corresponds well with direct intra-abdominal catheters and insufflation during laparoscopyReliable and reproducible

Abdominal Compartment SyndromeNew Perspectives on Old Concepts

Abdominal Compartment SyndromeEVMS ExperienceResuscitation greater than 12 liters in the first 24 hours was a risk factor for the development of secondary abdominal compartment syndromeR.C. Britt, et. al.

Balough, The American J. of Surg. 2003

Abdominal Compartment SyndromePossible Prevention StratagiesACS carries high mortalityAbdominal decompression also has high morbidity and mortalityAt risk groups can be identified High volume resuscitations (burns, traumas)Pts post hemorrhage and shockACP can be easily measured

Abdominal Compartment SyndromePeritoneal Catheter PlacementAbdominal pressures over 20 mmHgAbdominal perfusion pressures (APP) less than 50mmHgAbdominal perfusion pressure equals the mean arterial pressure minus the abdominal pressure. (MAP ACP = APP)

Results Total GroupThirty minutes after the DPL catheter was placed: (Avg starting ACP was 24.9mmHg)Average ACP decreased 7.7mmHg (p=0.003)Average MAP increased 9.7mmHg (p=0.02)Average APP increased 17.4mmHg (p=0.007)Average Pulm Compliance increased 7.9 (p=0.002)

Abdominal Trauma Case Report19 y/o male motorcycle crashMultiple rib fracturesFacial fracturesBilateral Tibia/fibula fracturesGrade I spleen laceration

Abdominal Trauma Case ReportHad both lower extremities repaired on HD#2Rib fractures managed with pain control and pulmonary toiletFacial fractures repair on HD#5Spleen observedLeft ICU on HD#4 and went to floor

Abdominal Trauma Case ReportMorning rounds HD#8HR 70 to 80 bpmBP 120/75Using only Percocet for painH/H 11/33Planning D/C home soon

Abdominal Trauma Case Report10pm Nurse called for increased pain in Left ShoulderDetermined this was a new complaint and no shoulder injury was documentedRepeated vital signsHR 110BP 95/50Patient was diaphoretic and pale

Abdominal Trauma Case ReportNurse immediately contacted house staff with new complaints and vital signsPatients seen and examinedAbdomen now tender with guardingRepeat H/H 6.5/19

Abdominal Trauma Case ReportEmergent Abdominal CT Scan revealed massive hemoperitoneum and delayed rupture of the spleenTaken immediately to OR for emergent splenectomyDid well and was discharged on HD#13

Abdominal Trauma Nursing QuoteI dont need to know exactly what is wrongI just need to know that something is wrong

My Mom