Case Report – History of Fall

and Admitted with shock

S.Gobishangar
05/09/2009
Case Report
A 53-year-old well-built man slipped on the
floor and landed on his back
He continued to suffer from sharp abdominal
pains gradually increasing in severity for the
following few days
The pain was localized in the epigastrium, left
hypochondrium and the back.
As he didn’t bother about his fall, his local
doctor attributed these pains to gastritis.
Fourth day following his trauma, he presented
to the Casualty Unit with shock and abdominal
pain
He could not give relevant history as his level
of consciousness continued to deteriorate.
None of his family members who were
accompanying him knew about his trauma.
On Examination
SBP 50-60 mmHg
HR 130 bpm.
Inspection showed an abdominal mass.
Abdominal wall was tender and rigid
The mass was fixed and not pulsating
Intensive resuscitation measures started
immediately
Blood was taken for cross match and investigations
The decision of exploration laparotomy was made.
The patient was temporary resuscitated, and on the
way to the operating room, he had a rapid CT
examination (without contrast)
It was difficult to maintain his vital signs that
started to deteriorate again; so he was rushed to
theatre.
The CT scan showed a huge multi-locular abdominal
cyst with blood-dense fluid inside
The origin of the cyst was not clear due to its size
Certainly, the possibility of a leaking aortic aneurysm
was excluded.
There was no other abnormal finding
At the laparotomy,
A huge dark blue cyst was filling most of the
abdominal cavity and pushing the entire bowel to a
small compartment
Opening the cyst revealed dark blood clots and
altered blood
The cyst was multi-locular as shown on the CT
The blood clots were removed and the loculi were
traced down to the retroperitoneal space
The retroperitoneal space was full of blood clots of
unidentified origin
There was no active bleeding.
The patient by this time received 15 units
of blood and 12 units of FFP
The cyst pseudo-wall, which actually
was derived from the retroperitoneal wall,
was closed by continuous vicryl suture to
tamponade the remaining hematoma.
The patient was transferred to the ICU
He stayed there for 3 days and was
transferred to the ward
He was discharged 10 days after his
laparotomy
One month later, a follow-up CT scan showed re-
accumulation of some blood clots and mild left
hydroureter and hydronephrosis.
The patient was asymptomatic, but to avoid further
pressure on his left kidney, he underwent an elective
laparotomy.
A smaller multi-locular blood cyst was identified,
opened and evacuated and the cyst wall was left open
for drainage
The abdomen was closed with two drains inside
The patient went home on the 5th
postoperative day
Six months follow up by abdominal
ultrasound revealed no back pressure on
the left kidney and absence of abdominal
cysts or masses
Management of Traumatic
Retroperitoneal Bleeding
Types of Retroperitoneal Bleeding
Spontaneous
Iotrogenic
Traumatic
Blunt trauma
Penetrating Trauma
Aetiology
Central retroperitoneum
Avulsion of Small branches from Aorta, IVC
Superior mesenteric artery
Portal vein
Lateal retroperitonum
GU (Kidney, Adrenal glands, Ureters, Bladder)
Pelvic retroperitoneum
Pelvic Fracture sites, Disruption of deep pelvic
artery
Blunt Injuries
Can explain by 3 mechanisms
Rapid deceleration causes differential movement
among adjacent structures
 Thisproduces shear forces which causes tear in hollow,
solid, visceral organs and vascular pedicles
Intra-abdominal contents are crushed between
anterior abdominal wall and vertebra / posterior
thoracic cage
External compression forces causes sudden and
dramatic increase in the intra-abdominal pressure.
 This produces rupture of hollow viscous organ
History
Detail history of injury
Mechanism of Injury, Vehicle, Speed
Time of injury
Abdominal trauma
Urine colour
Examination
General examination
Hydration
Pale, Dyspnoic
CVS
Low BP, PR, peripheral pulses
Abdominal examination
Distended abdomen
Bruising over the abdomen
Seat belt marks
Penetrating injury
Grey Turner sign
Cullen sign
Chest
Flail chest in lower ribs
Bowel sounds in the chest
Rectal examination
Blood
Any bony injuries in the pelvis
Investigation
Haematological
Hb
US Abdomen
CT
Angiography
Assess the renal injury
IVU, CT/IVU
Treatment
Initial Primary survey and Resuscitation
Urgent Blood transfusion
The non-operative or operative approach
is based on
Mechanism of injury
Hemodynamic status of the patient and
Extent of associated injuries
Therapeutic embolization
Indication for Laparotomy
Persistent haemodynamic instability
despite intensive volume replacement
 RPB at upper central area after
penetrating trauma implies damage to
great vessels – Always require urgent
exploration
After blunt trauma
Retroperitoneal hematomas in the lateral
perirenal and pelvic areas do not require
operation and should not be opened if
discovered at operation.
Midline, lateral paraduodenal, lateral
pericolonic not associated with pelvic, and
portal hematomas are opened
Retrohepatic hematomas without obvious
active hemorrhage are not opened.
After penetrating trauma
Most retroperitoneal hematomas are opened.
Exceptions include isolated lateral perirenal
hematomas & lateral pericolonic haematomas
Retrohepatic haematomas without obvious
active hemorrhage are not opened
Bladder Injury
Extra-peritoneal rupture of the bladder
may be managed non-operatively, intra-
peritoneal rupture mandates laparotomy.
Damage control surgery
Patients with hemorrhagic or traumatic
shock who have preoperative or develop
intra-operative severe metabolic
derangements which will adversely affect
survival
Stages of “Damage Control” Surgery

1. Limited operation for control of

hemorrhage and contamination
2. Resuscitation in the SICU
3. Reoperation
Retroperitoneal Haematoma

Expanding Not Expanding

Penetrating Trauma Blunt Trauma

On Table IVP to assess Contralateral Kidney

On Table IVP Don’t Explore

Explore
Follow up
Retroperitoneal bleeding patients need
follow up
USS / CT
May need re-evacuation of Haematoma
THANK
YOU