TOPIC- PRESENTATION

BLUNT TRAUMA ABDOMEN AND SOLID ORGAN INJURY

PRESENTED BY
Dr. AMIT MISHRA
PG-1
 Blunt Abdominal Trauma
Injury caused to abdomen by blunt force acting either directly or
indirect impact .
Greater mortality than PAT (more difficult to diagnose, commonly
associated with trauma to multiple organs/systems)
Most commonly injured organs: spleen (40-55%) > liver (30-
45%),>intestine(5-10%) is the most likely hollow viscus.
Most common causes: MVA (50 - 75% of cases) > blows to abdomen
(15%) > falls (6 - 9%)
most common cause of death for all individuals between the ages of
1 and 44 years
third most common cause of death regardless of age
Mechanism of Blunt Trauma
• Result from the impact force and deformation related to deceleration
and compression.
• Impact force = magnitude and duration; Deformation = strain
• Strain{Compressive/ crushing:Shearing /opposing:Tensile /stretching}
• Strain > elasticity or viscosity = disruption/injury
MECHANISM
• CRUSHING:-direct application of blunt force to abdomen.
• SHEARING:-sudden decelerations apply shearing force across organs
with fixed attachments.
• BURSTING:-raised intra luminal pressure by abdominal compression
in hollow organs can lead to rupture
• PENETRATION:-spikes of bony fragment generated by blunt injury to
bony areas leading to secondary penetrating injury
INJURY PATTERN
• Solid organ laceration – spleen (40-55%), liver (35-45%), kidney
pancreas
• Rupture of small bowel or colon 5-10%
• Tear or avulsion of mesentery /pedicle of solid organ 5%
• GU injuries
• Vascular injury
• Fracture of Pelvis / Ribs & vertebrae
• Diaphragmatic rupture
• Abrasion/ laceration
DIAGNOSIS
• HISTORY
• CLINICAL EXAMINATION
• DIAGNOSTIC SURGICAL PROCEDURE
• INVESTIGATIONS
HISTORY
• Mechanism of blunt trauma (MVA/ direct blow/ FFH/ Explosion)
• Time and place of injury
• Type of collision (frontal/ lateral/ side/ rear/ rollover)
• Magnitude of force/Speed of Vehicle
• Status of other vehicle occupant
• Patient’s position in vehicle
• Duration of entrapment
• Use of protective gears/ safety devices
• Presence of alcohol or drug uses
• Presence of psychiatric illness
PRESENTATION
• H/O trauma
• Pain abdomen
• Abdominal distension
• Vomiting
• Haematuria/ urinary retention
• Loss of consciousness
• Abdominal wall injury
• Other associated injuries – # & OR dislocation,
EXAMINATION
• General Physical Examination: vitals PR ^ ,Low BP, Cold clammy skin
• Systematic Abdominal examination
– INSPECTION :Abrasions, ecchymosis, seat belt abrasions or contusion
,distension.
Flank, scrotum & perianal area – blood @ meatus, swelling, bruising,
laceration of perineum, vagina, rectum or buttocks (s/o open pelvic #)
– PALAPTION :Generalized /localised tenderness, rebound tenderness,
guarding, rigidity,# ribs
– PERCUSSION :tympany in gastric dilatation or free air; (shifting)
dullness with hemoperitoneum
–AUSCULTATION : Bowel sound +/-; Reliable only when initially present
and change later; bowel sound in thorax.
• DRE – evaluate sphincter tone and to look for blood, perforation, or a
high-riding prostate ( Ruptured urethra)
• Grey-Turner sign: Bluish discoloration of lower flanks, lower back;
associated with retroperitoneal bleeding of pancreas, kidney, or pelvic
fracture.
• Cullen sign: Bluish discoloration around umbilicus, indicates
peritoneal bleeding, often pancreatic hemorrhage.
• Kehr’s sign: (L) shoulder pain while supine; caused by diaphragmatic
irritation (splenic injury, free air, intra-abd bleeding)
• Balance sign: Dull percussion in LUQ. Sign of splenic injury; blood
accumulating in subcapsular or extracapsular spleen.
• Seatbelt sign: results from compression from an improperly
positioned (too high, over the abdomen instead of the bony pelvis) lap
seatbelt in a motor-vehicle crash
MANAGEMENT
• B/L I.V ACCESS
• URGENT BLOOD SAMPLES FOR LAB. INV.& BLOOD GROUPING
• CHECK AND MAINTAIN AIRWAY ,BREATHING , CIRCULATION,
• HEMOSTASIS, SPINAL STABILISATION/ LIMB SPINTAGE (if needed)
• RYLE’s tube :-
i)Relieve acute gastric dilatation ii)Decompress stomach before a DPL
iii)Remove gastric contents,iv)Blood in NGEsophageal/ upper GIT
injury (after excluding naso/ oro-pharyngeal sources)
• Urinary catheter (or SPC):-
i)Relieve retention ii)Decompress bladder before DPL iii)Monitor UO as
indicator of tissue perfusion iii)Gross hematuria trauma to
genitourinary tract & non renal intraabdominal organs
INVESTIGATIONS
• LAB
CBC, BLOOD GROUP,RFT, LFT, RBS,S. AMYLASE,S.LIPASE, U-R/M, Coag.
Profile
• RADIOLOGY
CXR , ABD- X RAY , X RAY PELVIS, limb X RAYS AS THE CASE MAY BE
Contrast X ARYS- IF THE CASE DEMANDS
(IVP,MCU,CYSTOGRAPHY,URETHEROGRAPHY,G I CONTRAST)
• ULTRASOUND
FAST ,e FAST
• IMAGING
NCCT,CECT
• OTHERS
ANGIOGRAPHY /ERCP
ABDOMINAL X-RAY

• Pneumoperitoneum – hollow viscus perforation

• Ground glass appearance – massive hemoperitoneum
• Dilated gut loops- retroperitoneal hematoma/ injury
• Retroperitoneal air outlining the right kidney – duodenal injury
• Double wall sign – air inside and outside the bowel
• Distortion or enlargement of outlines of viscera – hematoma in
relation to respective organs.
• Medial displacement of stomach – splenic hematoma
• Obliteration of Psoas shadow – retroperitoneal bleeding
• Pelvic bone fracture – bladder/urethral/rectal injury
• Fracture vertebra – ureter injury / retroperitoneal hematoma
CHEST X RAY
• Pneumothorax/haemothorax
• Raised left/right hemidiaphragm – perisplenic/hepatic hematoma
• Lower ribs fracture – liver/spleen injury
• Abdominal contents in the chest – ruptured hemidiaphragm
FAST
Focused Assessment Sonography in Trauma.
-To diagnose free intraperitoneal fluid. Evaluate solid organ hematoma
• Rapid, accurate, non invasive, inexpensive study
• Operator dependant
• Views - 4Ps
-Pericardial view (Subxiphoid/ parasternal view)
-RUQ view - diaphragm-liver interface and Morrison’s pouch (Sagittal
view in MAL in 10th or 11th ICS) [Perihepatic]
-LUQ view - diaphragm-spleen interface and spleen-kidney interface
(Sagittal view in MAL in 8h or 9th ICS) [Perisplenic]
-Suprapubic view (Transverse; before inserting foley’s) [Pelvis]
FAST
• Low frequency (3.5 MHz) transducer; allows depth of penetration
necessary to obtain appropriate images
• ± Second scan 30 min after initial scan - progression
• Negative FAST doesn’t rule out intra-abdominal injury
• Difficult in subcutaneous emphysema, obese & old operated patients
• Pelvic # may decrease the accuracy.
• With pregnant trauma patients, detects gestational age & fetal viability
• Absolute indication for a laparotomy = contraindication for FAST
• (E-FAST):extended fast--- Add thoracic windows to look for
pneumothorax. Sensitivity 59%, specificity up to 99% for BTC
DPL
• Open, semi-open or closed method
• For unstable patients with –ive or equivocal FAST
• Performed via infra umbilical incision except in pelvic # & advanced
pregnancy (supraumbilical). Linea alba sharply incised, catheter directed
into pelvis, initial aspiration of abdominal contents done with 10cc syringe.
• Gross blood aspirated – go for Laparotomy
• No gross blood – instill 1 lit of warm NS (child – 10ml/kg) – gently agitate
the abdomen (compress abd. & then logross the patient)
• Adequate fluid return is > 20% of infused volume
• Negative lavage doesn’t exclude retroperitoneal injuries e.g. pancreatic or
duodenal injuries
• 98% sensitivity 96% specificity for intraperitoneal bleed
DPL
• Absolute contraindication = obvious need for laparotomy
-{Peritonitis, Injured diaphragm or evisceration, Extraluminal air on x-
ray, Significant intraabdominal injury on CT scan, Intraperitoneal
perforation of the bladder on cystography }
• Relative contraindications
-Pregnancy ; Advanced cirrhosis
- Morbid obesity ; pre existing coagulopathy
-H/o multiple abdominal surgeries
• Positive if
-10 ml grossly bloody aspirate before infusing lavage fluid
->100,000/μL RBCs; >500 /μL WBCs; Only 30mL blood reqd to produce
microscopically positive DPL result
↑ amylase, bile > 10ml, bacteria, G.I. content, vegetable matter or
urine
DPL (complications)
• Hemorrhage (false positive results)
- secondary to injection of local anesthetic
-Incision of the skin or subcutaneous tissues
• Peritonitis due to intestinal perforation from the catheter
• Laceration of urinary bladder (if bladder full)
• Injury to other abdominal and retroperitoneal structures requiring
operative care
• Wound infection at the lavage site (late complication)
 ABDOMINAL CT
INDICATIONS
• Accurate for solid visceral lesions and its grading and intraperitoneal hemorrhage.
• Guide nonoperative management of solid organ damage.
• Sensitivity for solid organ is >95% but for enteric & for diaphragmatic 60% & for pancreatic
30% (organ specific).[Can miss some GI, diaphragmatic and pancreatic injuries ]
• Hemodynamically stable patient with +ive FAST
• Not in emergent need of laparotomy.
• equivocal findings on physical examination,
• – associated neurologic injury, or
• – Significant pelvic fractures
• – multiple extra-abdominal injuries.
• – Inconclusive FAST with • Persistent LUQ tenderness • Gross haematuria • Falling
Hematocrit
• ± Contrast administration (non-ionic contrast)
• Organ injury & extent Retroperitoneal/ pelvic organ injuries
• Free fluid with no hepatic/ splenic injury suspect GI or mesenteric trauma
CT PRESENTATIONS
• Contrast extravasation
• Intrabdominal Hemorrhage
• Presence of pseudoaneurysm
• Thickened bowel wall
• Streaking in the mesentry
• Free fluid without assoc. solid organ injury
• Free intraperitoneal air
• Source of bleeding
• Amount of blood in abdomen
• Precision of organ injury
• Verterbral / pelvic #
DPL Vs FAST Vs CT
DPL FAST CT
ADVANTAGES EARLY DIAGNOSIS Rapid (~2 mins) Most specific for injury
PERFORMED RAPIDLY • Portable 92-98% sensitive
TRANSPORT=NO • Inexpensive Non invasive
98% SENSITIVE • Technically simple, easy to train Retroperitoneal well seen
DETECTS BOWEL INJURY • Can be performed serially
INEXPENSIVE • Useful for guiding triage decisions in trauma patients
• Sensitivity 60-95% in detecting 100ml -500ml fluid.

DISADVANTAGES Invasive Does not typically identify source of bleeding, Cost

Low specificity • Requires experience Time
Misses injury to diaphragm and • Limited in detecting <250 cc Transport required
retro peritoneum • Particularly poor at detecting bowel ,mesentery, Misses diaphragm, bowel and
diaphragm and pancreatic damage (44% sensitivity) few pancreatic injury
• Difficult to assess retroperitoneum Radiation exposure
• Limited by habitus in obese patient
• Operator dependent
• Bowel gas and s/c air distortion
• No radiation exposure . No contrast required

INDICATIONS Unstable blunt trauma, Unstable blunt trauma stable blunt trauma
Penetrating trauma Penetrating back/flank trauma
OPERATIVE INDICATIONS
• Blunt abdominal trauma with hypotension with a positive FAST or
clinical evidence of intraperitoneal bleeding
• Blunt abdominal trauma with a positive DPL
• Bleeding from the stomach, rectum, or genitourinary tract from
penetrating trauma
• Peritonitis after Blunt trauma
• Free air, retroperitoneal air, or rupture of the hemidiaphragm
• CT suggestive of ruptured GIT, intraperitoneal bladder injury, renal
pedicle injury, or severe visceral parenchymal injury after blunt
trauma
 LAPAROTOMY
• Generous midline incision
• Transverse incision in children < 6 yrs
• Remove blood and blood clots with abdominal swabs
• Palpate spleen and liver first and pack if fractured
• Source localizeddirect digital occlusion (vascular injury) or pad packing (solid
organ injury)
• Liver bleed –> hepatic pedicle clamping with vascular clamp (Pringle manoeuvre)
• Clamp the splenic hilum. If needed Mobilize the spleen
• Infracolic mesentry to be routinely inspected.
• Source of enteric contamination to be identified
• Anterior and posterior stomach to be inspected
• Duodenal injuries evaluated with kocher maneuver
• Pancreas examined during exploration of lesser sac
LAPAROTOMY
• Splenic bleed –> clamp splenic hilum (better than packing alone)
• Rotate spleen medially
• Incise lateral peritoneum & endoabdominal fascia
• Spleen and pancreas can be dissected from retroperitoneum as a
composite , ant. to Gerota’s fascia
• Scalpel better than cautery.
• Forget the bleeding from incision till definite source of bleed found
ALGORITHM FOR BTA EVAUALATION
INDICATIONS FOR CT
HEMODYNAMICALLY ALTERED MENTAL
STABLE PATIENT N N STATUS
Y
PERITONITIS CONFOUNDING
FAST
INJURY
N Y N GROSS HEMATURIA
FALLING HCT
PELVIC #
FAST LAPAROTOMY ABDOMINAL
+ TENDERNESS
CANDIDATE FOR
NON OPERATIVE
TREATMENT OR
PATIENT WITH Y
DPL CIRRHOSIS ABDOMINAL
CT
LIVER TRAUMA

• Primary aim is to arrest bleeding

• Perihepatic packing is effective most of the times, if not then perform
Pringle manoeuvre
• Difficult to perform perihepatic packing in Lt lobe Mobilize it and
compress between surgeon’s hands
• Pringle manoeuvre
-Bleeding stopped => from AHA / PV
- Doesn’t stop => HVs and retrohepatic IVC is the
sourcePackingFailed direct vascular repair ± hepatic vascular
isolation
• Repair the Hepatic artery proper
• Cholecystectomy if Rt hepatic artery is ligated
LIVER TRAUMA GRADING (AAST)
American Association for surgery of trauma grading scales of
solid organs injuries
SUBSCAPSULAR HEMATOMA LACERATION
LIVER INJURY GRADE
GRADE I < 10% of surface area < 1 CM IN DEPTH
GRADE II 10-50% of surface area 1-3

GRADE III >50%of surface area OR > 10cm in >3 CM

depth
GRADE IV 25-75% of hepatic lobe

GRADE V >75% of hepatic lobe

GRADE VI Hepatic avulsion

LIVER TRAUMA
• Minor lacerations
-Manual compression
- Topical hemostats (cautery, Abgel/ Gelfoam, fibrin glue, collagen)
• Shallow lacerationsrunning suture
• Deep lacerations
-Interrupted mattress parallel to edge of laceration
-Omentum to fill large defects (obliterates dead space; source of
macrophages)
• Deep recalcitrant haemorrhagehepatic lobar arterial ligation
LIVER TRAUMA
• Repeat laparotomy within 24 hrs for pack removal
• Ongoing hemorrhage – early exploration (<24hrs)
• Complex injuries – angioembolization (increasing importance)
• Non-anatomical resection – stable without coagulopathy
• GB injury cholecystectomy
• EHBD Transaction  Roux-en-Y choledochojejunostomy
• Till then intubate the duct for external drainage by T tube.
• Complications – hemorrhage, hepatic necrosis, bilomas, arterial
pseudoaneurysms and biliary fistula. Complex injuries – typical ‘liver fever’
upto 5 days post injury
LIVER TRAUMA – NON OPERATIVE
MANAGEMENT (NOM)
• Basis
-50-80% of liver bleed stops spontaneously
-Better results of NOM in children Significant development of CT scan in liver
imaging
• Initially introduced for minor injuries.
• Presently being used for grades III – V also
• Selection criteria
-Hemodynamic stability after initial resuscitation
-absence of peritoneal signs
-No other visceral/ retroperitoneal injuries needing surgery.
-Multidisciplinary team – Experienced surgeon, Intensivist, CT scan, 24x7 OT
facilities
LIVER TRAUMA – NON OPERATIVE
MANAGEMENT (NOM)
• Absolute bed rest & NPO
• Failure rate significantly higher in Gd IV & V than Gd I--III
• Most common reason for intervention – co-existing abdo injury (e.g. bleed form
spleen or kidney)
• Predictors of NOM failure
-Advanced age
- Anaemia & HTN
-Active extravasation on CT
-Massive blood transfusion
• CT follow up for Gd I & II not necessary
• Others need clinical and CT follow up
SPLENIC TRAUMA
American Association for surgery of trauma grading scales of
solid organs injuries
SUBSCAPSULAR HEMATOMA LACERATION

SPLENIC INJURY GRADE

GRADE I < 10% of surface area < 1 CM IN DEPTH

GRADE II 10-50% of surface area 1-3 CM

GRADE III >50%of surface area OR > 10cm in >3CM

depth

GRADE IV >25% Devascularisation HILUM INJURY

GRADE V Complete Devascularisation

Shattered spleen
SPLENIC TRAUMA
• Management options
-Observation
-Angiographic Embolization (Gd I-III; age < 55y)
-Surgery (Splenectomy/ partial splenectomy/ splenorrhaphy).
• Depending upon
-Hemodynamic status of pt
-Grade of injury
-Presence of other injuries
-Medical co-morbidities
• Upto 20% patients require early splenectomy
• Delayed hemorrhage/ rupture can occur weeks after injury
SPLENIC TRAUMA
• Splenectomy (with auto-transplantation)
-Hilar injuries
-Pulverized splenic parenchyma
-GD III and above + coagulopathy/ multiple injuries
• Partial splenectomy – isolated polar injuries
• Splenorrhaphy – cautery, Abgel/ gelfoam, fibrin glue, collagen,
envelopment in absorbable mesh, pledgeted suture repair
• Bleeding edges – Hz mattress sutures + parenchymal compression
SPLENIC TRAUMA
• Post splenectomy hemorrhage
-Loosening of tie around splenic vessels
-Improperly ligated/ missed short gastric artery
-Recurrent splenic bleed.
• Post-op complications
-Subphrenic abscess (pigtail drainage)
-Pancreatic tail injury (Iatrogenic)
-Gastric perforation (during short gastric ligation)
-OPSI
SPLENIC TRAUMA – NON OPERATIVE
MANAGEMENT (NOM)
• Basis
-Salvaging functional splenic tissue – avoids surgical & anesthetic
complications
-No risk of post-splenectomy abscess
Indications
-Hemodynamically stable patients (Gd I - III)
-No other intra-abdominal injuries needing laparotomy
- Small Active contrast extravasation/ blush on CT
• > 70 % patients still undergo splenectomy after NOM
• Higher failure rates of NOM with increasing grades of severity
• Most failures occur within 72 hours of injury.
SPLENIC TRAUMA – NON OPERATIVE
MANAGEMENT (NOM)
• Absolute bed rest & NPO
• Regular Hb check
• Allowed orally if Hb stable & no surgical intervention likely
• Follow-up CT: Falling Hb, abdo. pain, fever, Lt shoulder pain
• Duration based on
-Grade of splenic injury
-Nature & severity of other injuries
-Clinical Status (Include peritoneal signs – missed hollow viscus injury & Hb
levels)
Embolization – 73-97% success rate
STOMACH & INTESTINE
• Gastric Wounds – running single layer suture (full thickness bites)/ stapler
• Partial gastrectomy – for destructive injuries .
• Control contamination and assess
• Small intestine injury of < 1/3rd of bowel circumference
• transverse running 3-0 PDS
• Multiple injuries/ mesenteric injuries – segmental resection and
anastomosis/ stoma
• Post-op ileus is obligatory
• No enteral feeds for at least 48 hrs
• TEN to be started at 20mL/h once resuscitation is complete
Small intestinal injuries
• A blunt trauma cause is less common, but not rare (10%-15%)
• Larger perforations, complete disruptions, and injuries associated
with large mesenteric hematoma or lacerations are caused by direct
blows or shearing injury or contusion.
• Perforation from blunt injury is most common at the ligament of
Treitz, ileocecal valve, midjejunum, or in areas of adhesions.
• Small isolated perforations probably result from blowouts of pseudo-
closed loops (seatbelt-related injuries).
DUODENUM
• Duodenal hematoma – NG aspiration & parenteral nutrition
• Small duodenal perforation/ laceration – primary single layer repair
• 1st part injuries – debridement & end-to end anastomosis with
gastric antrum/ pylorus
• 2nd part injuries – patch with vascularized jejunal graft
• 3rd & 4th part injuries – resection and anastomosis on Lt side of
Superior mesenteric vessels
• Pyloric exclusion – high risk, complex duodenal repairs
 PANCREATIC INJURY
• Relatively uncommon in BTA. Associated intraabdominal injury is found in >90%
of pancreatic injuries.
• CT may identify peripancreatic hematomas but may not identify pancreatic
lacerations or even complete transections early
• (ERCP) or (MRCP) can be used to diagnose pancreatic ductal injury in
hemodynamically stable patients.
• Intraoperative diagnosis depends on visual inspection and bimanual palpation
of the pancreas by opening the gastrocolic ligament and entering the lesser sac,
and by performing a Kocher maneuver.
• Mobilization of the spleen along with the tail of the pancreas and opening of
the retroperitoneum to facilitate palpation of the substance of the gland may
be necessary to determine transection versus contusion.
• Identification of injury to the major duct is the critical issue in intraoperative
management of pancreatic injury.
PANCREAS
• Treatment principles include i] Control hemorrhage (Hemostasis)
ii]Debride devitalized pancreas, which can require resection (Debridement)
iii]Preserve maximal amount of viable pancreatic tissue (Preservation)
iv]Wide drainage of pancreatic secretions with closed-suction drains (Drain)
v]Feeding jejunostomy for postoperative care c’ significant lesions (Feeding)
• Management depends on location of injury to
i-Parenchyma ,ii-Intrapancreatic CBD, iii-MPD
• Contusion (ductal system intact)/ proximal pancreatic injuries (to Rt of SM
vessels)
-Non operative/ closed suction drain
• Distal duct disruption (body & tail) – distal pancreatectomy with splenic
preservation
• Injury to Head with duct injury – distal duct ligation with Roux-en-Y
choledochojejunostomy
• Severe injury to both the head of the pancreas and the duodenum may
require Whipple pancreaticoduodenectomy.(Rare)
COMPLICATIONS
• Pancreatic abscess
• Post-traumatic pancreatitis
• Pancreatic pseudocysts occur in 2% to 4%
• Haemorrhage
• Overall mortality ranges from 15% to 35% with pancreatic-related
mortality alone ranging from 2% to 3%.
COLON & RECTUM
• 3 methods for colonic injuries
-Primary repair
-End colostomy
-Primary repair with diverting colostomy
Weigh the risk of primary repair Vs colostomy
• Lt colon injuries - Temporary colostomy
• Other high risk pts - Diverting ileostomy with colocolostomy
• Rectal injuries – loop ileostomy/ sigmoid loop colostomy
• Accessible rectal injury – attempt primary repair with diversion
• Extensive rectal injury – End colostomy (Hartmann’s)
• Complications: Intra-abdo. abscess, fecal fistula, infection, stomal complications
GENITOURINARY TRACT INJURY
• 90 % Renal injuries managed conservatively
• Hematuria resolves in few days with absolute rest
• Operative intervention – Hypotension due to
-Renovascular injuries
-Destructive parenchymal injuries
• Persistent gross hematuria – embolization
• Urinoma – Percutaneous drainage
• Renal artery repair
-Success rates very low
-Image guided endostent placement can be attempted
GENITOURINARY TRACT INJURY
• Renorrhaphy
-Take vascular control for proper visualization
-Preserve renal capsule
-Collecting system is closed separately with absorbable sutures
-Preserved capsule is closed over collecting system repair
• Ureter injuries
-Primary repair with renal mobilization for tension relief
-Reimplantation (with psoas hitch) for distal ureter injuries
-Damage control – B/L ligation + Nephrostomy
GENITOURINARY TRACT INJURY
• Bladder injuries
• Intraperitoneal injuries-due to direct blow to bladder or deceleration,seat belt injury
-Running, single layer 3-0 absorbable monofilament suture
-Lap repair – if other injuries not needing repair.
• Extraperitoneal injuries –assoc. c’ pelvic #
-Non Operative tt with bladder decompression for 2 wks.
• Uretheral injuries- Ruptured urethra (high riding prostate, scrotal
hematoma, blood @ meatus)
-Bridge the defect with Foley’s catheter
-Elective repair for strictures later
VASCULAR INJURIES
• TREATMENT OPTIONS
OBSERVATION
LIGATION
LATERAL SUTURE REPAIR
END TO END ANASTOMOSIS
INTERPOSITION GRAFTS
-AUTOGENOUS VEIN
-PTFE GRAFT
DACRON GRAFT
TRANSPOSITIONS
EXTRA ANATOMIC BYPASS
INTERVENTIONAL RADIOLOGY
-STENTS
-EMBOLISATION
ABDOMINAL COMPARTMENT SYNDROME
• DEFINITION:- Symptomatic organ dysfunction that results from
increased intraabdominal pressure (IAP).
• Incidence of ACS in trauma patients is 2-9%.
• Increased IAP is an under-recognized source of morbidity and
mortality.
ETIOLOGY
• Massive volume resuscitation in the leading cause of ACS.
• Inflammatory states with capillary leak, fluid sequestration,
inadequate tissue perfusion, and lactic acidosis can develop ACS.
• Gastric overdistention following endoscopy has resulted in ACS.
ACS
INTRABDOMINAL HTN
• PRIMARY CAUSE- Intra-abdominal injury
• SECONDARY CAUSE- splanchnic reperfusion after massive resuscitation
sources of increased IAP include gut edema, ascites, bleeding, and packs,
among others.
The cause of edema is multifactorial. – Ischemia and reperfusion cause
capillary leakage;/ dec oncotic pressure/ venous or lymphatic obstruction.
ABD.COMPT. SYND is said to be the end organ sequalae of intraabdominal
hypertension.
ACS @ RISKS PATIENTS:- a)MAJOR TRAUMA, b)DAMAGE CONTROL SURGERY,
c)LAPAROTOMY FOR ISCHEMIA,BLEEDING,d)RE LAPAROTOMY FOR POST OP.
COMPLICATIONS e) MASSIVE VOLUME RESUSCITATION.
CLINICALLY:-ABD. DISTN, I^ IAP, ORGAN DYSFNC.
IMPORTANCE:-DECOMPRESSION can reverse abn. Physiology.
Probable fatal progression if left untreated.
PATHOPHYSIOLOGY-ACS
• The IAP is usually 0 mmHg during spontaneous respiration
• Slightly positive in the patient on mechanical ventilation
• IAP increases in direct relation to body mass index.
• Supine hospitalized patients had a mean baseline value of 6.5 mmHg.
• The compliance of the abdominal wall limits the rise in IAP but increases
rapidly after a critical IAP
• Critical IAP varies from patient to patient, based on abdominal wall
compliance on perfusion gradient
• IA HTN often defined as IAP > 12mmHg
• Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall
compliance and can be protective
CLINICAL MANIFESTATIONS--ACS
• CNS
- ^I Intracranial pressure
- decre.Cerebral perfusion pressure
RESP.
^Intrathoracic pressure;^Airway pressures;!Compliance;!PaO2 ;^PaCO2 ;^Shunt
fraction ;^Vd/Vt
CVS
-Hypovolemia; !Cardiac output ; !Venous return ; ^ PCWP and CVP ; ^SVR
RENAL
!Urinary output;!Renal blood flow ; !GFR
HEPATIC
- !Portal blood flow; !Mitochondrial function ; ! Lactate clearance
ABD. WALL
- !Compliance ; ! Rectus sheath blood flow
GIT
- !Celiac blood flow; !SMA blood flow ; !Mucosal blood flow ; !pHi
IAP MEASUREMENT
• 50 mL of sterile saline is instilled into the bladder via the aspiration
port of the Foley catheter with the drainage tube clamped.
• An 18-gauge needle attached to a pressure transducer is then
inserted in the aspiration port, and the pressure is measured. The
transducer should be zeroed at the level of the pubic symphysis.
ACS- MANAGEMENT
GRADING OF ACS
GRADE PRESSURE (mm Hg) MANAGEMENT

I 10-15 Normovolemia maintenance

II 16-25 Volume administration

III 26-35 Decompression

IV >35 Re-exploration
OPERATIVE DECOMPRESSION OF ACS
• Vacuum-assisted temporary abdominal closure device:
• Thin plastic sheet, a sterile towel, closed suction drains, and a large
adherent operative drape. This dressing system permits increases in
intra-abdominal volume, without a dramatic elevation in IAP.
• Abdominal Perfusion Pressure (APP): APP = MAP .The inability to
maintain an APP above 50 mmHg predicted mortality with greater
sensitivity and specificity than either IAP or MAP alone
ACS -Summary
• ACS is a clinical entity caused by an acute, progressive increase in IAP.
• Multiple organ systems are affected, usually in a graded fashion.
• The gut is the organ most sensitive to IAH.
• Treatment involves expedient decompression of the abdomen.
• Pt already physiologically compromisedKeep high degree of
suspicion and a low threshold for checking bladder pressures to
prevent the associated mortality
DAMAGE CONTROL SURGERY
• The purpose is to limit operative time so the physiological restoration
is possible
• The objective is – Control surgical bleeding – Limit GI spillage
• Using temporary measures.
• PRINCIPLES are: • Control hemorrhage with packing • Identification of
injury • Prevention and control contamination with temporary closure
• Avoid further injury • Resuscitation in the ICU • Re-exploration and
definitive repair once normal physiology has been restored
DAMAGE CONTROL SURGERY-
intraoperative indications for damage control surgery
Factor Level
• Initial body temperature < 35°C .
• Initial acid-base status ·
– Arterial Ph <7.2 ·
– Base deficit < –15 mmol/l for < 55
< –6 mmol/l for > 55
– Serum lactate > 5 mmol/l .
• Onset of coagulopathy
– PT and /or PTT > 50 % of normal
DAMAGE CONTROL SURGERY
3 phases
1.Limited operation for control of hemorrhage and contamination •
Ctrl Hemo./ Resection, repair / Packing/ Alternate closure or coverage
2. Resuscitation in the SICU • Rewarm / Restore loss/ correct/ support
/ monitor for ACS
3. Reoperation 12 – 24 hr • Completion of definitive repairs / search
for injuries / formal closure
DAMAGE CONTROL SURGERY
• Bowel Injuries – Complete transection of bowel of segmental damage
with GI stapler – Whip stitch 2-0 prolene for small injuries – Open end
ligated using umbilical tape
• Vascular Injuries – Interposition PTEE graft for Aortic injuries – Celiac
artery can be ligated – SMA must maintain flow - insertion of
intravascular shunt – Ligation of venous injuries except for supra renal
IVC and Popliteal vein
• Solid organs – Excision rather than repair – Packing and compression
tamponade
• Abdomen closed temporarily ( TOWEL CLIPS/ DRAPE)
summary
• Aim should be to save life rather consuming time for more
investigations for a refined diagnosis
• Abdomen is a black box ,not all injuries can be known by
investigations only. The goal is to manage any immediate threats to life
• Serial physical examination has the best sensitivity and negative
predictive value of all modalities for the evaluation of penetrating
abdominal trauma
• The primary objective of the physical examination in abdominal
trauma is to rapidly identify the patient who needs a laparotomy.
• Pulse, blood pressure, and urine output—hypovolemia + abdominal
signs
• Diag. Lap. & Expl. Laparotomy whenever needed.
• The term ‘Damage Control Surgery’ has yet to reach twenty years of
use as concept for the treatment of exsanguinating truncal trauma
patients & has become model for emergent, life threatening surgical
conditions incapable of tolerating traditional methods
SUMMARY
• NON OPERATIVE INJURY MANAGEMENT -General considerations
‘‘criteria for non operative management’’:- i)Patient hemodynamically
stable after initial resuscitation ii)Continuous patient monitoring for
48 hrs iii)Surgical team immediately available iv)Adequate ICU
support and transfusion services available v)Absence of peritonitis vi)
Normal sensorium
•Angioembolization may be alternative to surgical intervention
•All patients with solid organ injury managed non-operatively require
admission for observation, serial hematocrit measurement, and repeat
REFERENCES
References

[1] F. Brunicardi, D. Andersen, T. Billiar, D. Dunn and J. Hunter, Schwartz’s Principles of Surgery,
McGraw Hill, 2014.

[2] N. Williams, P. R. O'Connell and A. McCaskie, Bailey & love Principles of surgery, CRC, 2018.

[3] C. M. Townsend, R. D. Beauchamp, B. M. E. MD and K. L. Mattox, Sabiston text book of surgery,

Elsevier Saunders, 2012.

[4] S. Bhat, SRB Manual of surgery, JAYPEE, 2019.

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