PONGSASIT SINGHATAS, M.D. Department of Surgery
Faculty of Medicine, Ramathibodi HospitalMahidol University
Patient survive
Low morbidity
GOOD JUDGMENT COMES FROM
EXPERIENCE
EXPERIENCE COMES FROM
BAD JUDGMENT
Airway and Breathing first
Solid organ and Vascular injury => C
Hollow viscous injury => Sepsis
Investigate and assessment of abdomen base on three group
1)Normal abdomen
2)Equivocal require investigation
3)Obvious abdominal injury
Diagnosis modalities
1) PE
2) DPL
3) FAST
4) CT scan
5) Diagnostic laparoscope
Hemodynamically normal patient
Full evaluation and decision to surgery or
non-operative management
Hemodynamically stable patient
Will benefit from investigation aimed to
- Patient bled into abdomen ?
- Bleeding has stopped ?
- Hollow viscous injury ?
Hemodynamically unstable patient
Try to define bleeding is taking place e.g. pelvis
or abdominal cavity
FAST quicker than DPL but operator dependence
Negative DPL => very clear that the intra
abdominal bleeding is unlikely in unstable patient
Negative Exporation => Survive
Positive Unexploration => Dead
เจ็บฟร,ี เสียหน้า, เสียเวลา
Operative complication (GA, wound, adhesion)
Communication with patient and relative
Except Negative Exploration in Pelvic Fx
Unstable vital sign with
abdominal cause
or
Peritonitis
(Diffuse Abdominal tender)
Bowel content
Bile
Urine
Pancreatic juice
Blood
Difficult to exam in Head injury
Cord injuryIntoxication
Adequate analgesia
Never mask abdominal symptom
Make abdominal pathology easier to assess
- Clear physical sign
- Co-operative patient
FAST in unstable patient Positive => explore laparotomy
Equivocal => DPL/DPA or explore laparotomy
Negative => Find other bleeding, if not found DPL/DPA or explore laparotomy
No ultrasound available =>DPL/DPA
Not sent unstable patient to CT room
Abdominal sign Pelvic fracture with lower abdominal sign
CT or FAST not available
No other source in hemodynamic unstable
Distinguish blood from other type of fluid
DPA => gross blood in unstable patient
Trauma Mattox Edition6
Not BP only
Hypertensive patient ??
Sign of poor tissue perfusion
4 classification of hypovolemic shock
And
Responsibility after fluid resuscitation
Class I Class II Class III Class IV
For 70 kg male
2000 mLof isotonic solution in adult; 20 mL/Kg in children
Solid organ injury => liver, spleen, kidney,
pancreas
Vascular injury with interventionist
Need ICU
Need OR available
Need Surgeon available
Necessary to CT scan ??
- Triple contrast
- Solid parenchymal organ injury
- Free air (Plain film abdomen)
- Free fluid with Hounsfield Units
- Contrast extravasations (lumen and vessel)
- Injury grading
Limitation
- Hollow viscus
- Mesenteric injury
- Diaphragmatic injury- Bladder injury (need CT cystogram)
Trauma Mattox Edition6
Unstable Stable
FAST Positive EL CT
FAST Equivocal DPA +/- EL CT
FAST Negative Find other
bleeding, if not found DPA +/- EL
Repeat FAST
ObserveCT ??
CT not available ???
Not routinely
Stab wound
Anterior abdomen
No indication in Flank or back
Under local anesthesia
Positive => Penetration of posterior fascia
Rarely practice in trauma center
Trauma Mattox Edition6
Serial PE
Observe 24 hr
Ideal same surgeon
Frequent check V/S
Abdominal sigh every 4 hr
Persist local symptom => other modality evaluated
DPL
Unstable with other cause bleeding
Stable R/O hollow viscus or diaphragmatic injury
FAST
Not recomment
Routine laparotomy both stab and GSW
Increase conservative in stab woundLaparotomy in GSW
More conservative in GSW
Not routine in
anterior stab
wound
Recommend in
- Stab wound at
flank and back (15%
require surgical repair)
- GSW
Triple contrast
Wound tract
evaluated
Free air, free fluid
Contrast
extravasate
Intraluminal
contrast leak
Bowel wall defect
Trauma Mattox Edition6
Peritonitis
Unstable vital sign
Blood replacement??
Most common cause in trauma
Presumed hemorrhagic shock until proven
otherwise
Fluid resuscitation in early signs and
symptoms of blood loss
Principle is Stop the bleeding
and replace the volume loss
Whole blood is superior than component
therapy
PRBC:FFP ratio of 1:1 or 2:1
Platelet require in blood loss greater than
1.5 blood volume
อุดรูรั่วและเติมน ้าให้ทัน ถ้าตุ่มแห้ง => เลือดหมดตัว => ตาย
Exsanguination = Extensive Hemorrhage
- Large syringe connect to pressure source (human hand)
- IV pressure bag
- Pneumatic external pressurized intravenous infusion system
Increasing hematocrit and decreasing temperature => Increase blood viscosity
Controlled resuscitation, balance
resuscitation, permissive hypotension
Keep SBP 80-90 mmHg or 100 mmHg if head injury is suspected
Penetrating trauma with hemorrhage
No evidence in blunt trauma
Manual of Definitive Surgical Trauma Care, Boffard
Delay aggressive fluid resuscitation
until definitive control
Prevent additional bleeding
Balance of organ perfusion
and
Risk of rebleeding
(accept a low normal blood pressure)
Manual of Definitive Surgical Trauma Care, Boffard
Desire to reassess the intra-abdominal content (directed re-look)
Evidence of decline of physiology reverse
1)Initial body temperature < 34 C
2)Initial acid-base status
- Arterial pH <7.2
- Serum lactate > 5 mmol/L
- Base deficit <-15 mmol/L in patient <55 years
or <-6 mmol/L in patient >55 years
Manual of Definitive Surgical Trauma Care, Boffard
3)Onset coagulopathy
PT >16 sec or PTT >60 sec
>50% of normal
4)Other condition
- >10 unit blood
- SBP <90 mmHg more than 60 min
- Operating time >60 min
Control
1. Bleeding2. Contamination
Thoracotomy if indication
Laparotomy if indication
In unstable patient, what is first?
=> depend on ICD content
=> prep both chest and abdomen
Diaphragmatic injuryDifficult to diagnosis
Both hemothorax and hemoperitonem in one penetrate wound
Bowel content or NG tube at chest (Lt) from film chest in blunt
Should be repair by non absorbable
Laparoscopic diagnosis and repair is standard
Can repair from thoracotomy or laparotomy
11 in 28 (39%) mortality in unstable pelvic Fx
with laporotomy
FAST positive => retroperitoneal hematoma
passes into abdominal cavity
31 in 80 unstable pelvic Fx patients with free
fluid and undervent laparotomy
1 in 31 patient show retroperitoneal
hemaotoma alone
Mortality rate 35% in laparotomy group
J.K. Bryceland, Injury, Int. J. Care Injured 2008
Steffen R, J Trauma.2004;57:278 –286.
Trauma Mattox Edition6
Unstable
Secondary brain injury- Hypovolemic shock
- Polycompartment syndrome
Severe HI associated DIC- Now, conservative in solid organ injury is accept
- Threshold for laparotomy lower than non HI
Laparotomy or CT head first ??Laparotomy in patient with GCS 2T ??
Trauma Mattox Edition6
Trauma Mattox Edition6
Technique for temporary control of hemorrhagePerihepatic packing
Electrocautery or argon beam coagulator
Pringle’s manoeuvre
Hemostatis agent and glues
Hepatic suture -> large curve needle Chromic
Technique for temporary control of hemorrhageFinger fracture hepatotomy and
vessel ligation
Tract temponade balloon (Sengstaken tube)
Tractotomy and direct suture
Mesh wrap
Hepatic artery ligation
Technique for temporary control of hemorrhageHepatic resection
Hepatic vascular isolation
Atriocaval shunt
Veno-venous bypass
Hepatic vascular isolation
Pringle’s manoeuvre
Clamp IVC above Rt kidney (Suprarenal)
Clamp IVC above live (Suprahepatic)
Atriocaval shunt
Good exposure
Proximal and distal control
Anatomical distortion from hematoma
Active bleeding
- Pressure first
- Supraceliac control or Lt anterolateral
thoracotomy in aorta injury
- Supradiaphragmatic control in IVC
Manual of Definitive Surgical Trauma Care, Boffard
Retroperitoneal organ
In early of injury, abdominal exam is difficult
FAST or DPL maybe negative
Retorperitoneal free air in plain film
or CT)
High mortality if delay diagnosis
Should be Kocherization and open lesser sac in blunt abdominal injury
Trauma Mattox Edition6
Duodenal Inj
Trauma Mattox Edition6
Pancreatic Inj
Non-operativeIndication for surgery follow non-operative
Hemodynamic instable
Evidence of continued splenic hemorrhage
Associate intra-abdominal injury requiring
surgery
Replacement of more than 50% of blood volume
Spleen not active bleeding
-> left alone
Splenic surface bleeding only
-> packing, diathemy or fibril glue
Minor lacerations
-> absorbable suture use pledget, omental patch may be place
Splenic tears1) Mesh wrap -> absorbable mesh e.g. Vicryl
wrap from hilum and around parenchyma
2) Partial splenectomy -> ligating segmental vessel at hilum and seen demarcation ischemic pole
3) Splenectomy
Option
Primary repair
Resection
+/- anastomosis
+/- proximal
diversion
Diversion only
Depend on
Position of injury
=> Stomach, Small
bowel, Colon
Severity of injury
Contamination
Patient status
Can not conservative Need to Laparotomy
Aim of trauma is patient survive
Different resource => different judgment
Now, try conservative but patient safety is
most important
Don’t forget call for help
Damage control if indication