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Abdominal Trauma - Cpirozzi
Abdominal Trauma - Cpirozzi
Cheryl Pirozzi, MD
Fellows Conference 5/4/11
Abdominal Trauma
Plain films:
fractures nearby visceral damage
free intraperitoneal air
Foreign bodies and missiles
Angiography
To embolize bleeding vessels or solid visceral hemorrhage
from blunt trauma in an unstable pt
Rarely for diagnosing intraperitoneal and retroperitoneal
hemorrhage after penetrating abdominal trauma
trauma.org
Pericardium (subxiphoid)
forsurenot.com
Management of penetrating abdominal
trauma
Mandatory laparotomy
vs
Selective nonoperative management
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Mandatory laparotomy
standard of care for abdominal stab wounds until 1960s,
for GSWs until recently
Now thought unnecessary in 70% of abdominal stab
wounds
Increased complication rates, length of stay, costs
Immediate laparotomy indicated for shock, evisceration,
and peritonitis
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Selective management used to reduce unnecessary
laparotomies
Diagnostic studies to determine if there is
intraperitoneal injury requiring operative repair
Strategy depends on abdominal region:
Thoracoabdomen
Nipple line to costal margin
Anterior abdomen
Xiphoid to pubis
Flank and back
Posterior to anterior axillary line
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Thoracoabdomen
Big concern is diaphragmatic injury
7% of thoracoabdominal wounds
Diagnostic evaluation:
CXR (hemothorax or pneumothorax)
Diagnostic peritoneal lavage
FAST
Thoracoscopy
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Thoracoabdomen
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Anterior abdomen
Only 50-70% of anterior stab wounds enter the abdomen
of these, only 50-70% cause injury requiring OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of PAT
Anterior abdomen
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating abdominal
trauma
Gunshot wounds
Much higher mortality than stab wounds
Over 90% of pts with peritoneal penetration have
injury requiring operative management
Most centers proceed to lap if peritoneal entry is
suspected
Expectant management rarely done
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosens Emergency Medicine 2009
Management of PAT
Gunshot wounds
assess peritoneal
entry by missile path,
LWE, CT, US,
laparoscopy (all
limited)
ashwinearl.blogspot.com
Management of Blunt abdominal trauma
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
0. initial resuscitation
1. Control of hemorrhage and contamination
Control injured vasculature, bleeding solid organs
Abdominal packing
2. back to the ICU for resuscitation
Correction of hypothermia, acidosis, coagulopathy
3. Definitive repair of injuries
4. Definitive closure of the abdomen
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Damage Control
Open abdominal wounds and definitive closure
40-70% cant have primary closure after definitive repair.
Temporary closure methods
Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med 2010 38:S421-430
Abdominal Compartment Syndrome
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome
Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333-338
Abdominal Compartment Syndrome
Management
Surgical abdominal decompression
Nonsurgical: paracentesis, NGT, sedation
Staged approach to abdominal repair
Temporary abdominal closure
Bailey J. Crit Care 2000, 4:2329 Sugrue M. Curr Opin Crit Care 2005; 11:333-338
Conclusions