1. Abdominal traumaBy Dr.sadia Asmat BurkiTmo Surgical B wardSaidu teaching hospital

2. IntroductionAbdominal trauma means any injury occurring toabdominal cavity.In civilian life, the majority of abdominal injuriesare due to blunt trauma secondary to high speedautomobile accident.Penetrating injuries, often associated with wartimecombat, are seen with increasing frequency in EDparticularly in urban areas.The failure to manage abdominal injuriessuccessfully accounts for the majority ofpreventable deaths following multiple injuries, andthis accounts for the 10% of traumatic deaths thatoccur annually in the USA. 3. EpidemiologyUnited States statisticsTracking trauma is the purview of the National Centerfor Injury Prevention and Control (NCICP). Datacollected by this organization suggest that traumaticinjury is the third overall leading cause of death andthe number one cause of death in persons aged 1-44years. Penetrating abdominal trauma affectsapproximately 35% of those patients admitted tourban trauma centers and 1-12% of those admitted tosuburban or rural centers.[3]More than 150,000 people die each year as a resultof injuries, such as motor vehicle crashes, fires, falls,drowning, poisoning, suicide, and homicide. Injuriesare the leading cause of death and disability for USchildren and young adults. 4. International statistics In 1990, approximately 5 million peopledied worldwide as a result of injury. Globally, injury accounts for 10% of alldeaths. Estimates indicate that by 2020, 8.4million people will die yearly from injury. A review from Singapore describedtrauma as the leading cause of death inthose aged 1-44 years. Traffic accidents,stab wounds, and falls from heights werethe leading modes of injury. Bluntabdominal trauma accounted for 79% ofcases. 5. Anatomy of abdomen 6. ExternalAnatomyAnterior abdomen; transnipple linesuperiorly, inguinal ligaments andsymphasis pubis inferiorly, anterioraxillary lines laterally.Flank; b/w anterior and posterioraxillary lines from 6th intercostalsspace to iliac crest.Back; Posterior to posterior axillarylines, from tip of scapulae to iliaccrests. 7. Internal Anatomy Consists of four parts; Intrathoracic abdomen Pelvic abdomen Retroperitoneal abdomen True abdomen 8. Intrathoracic abdomenLiverSpleenDiaphramStomachBut cartilagionus andbony sturctures makethis portion inaccessibleto palpation.Eachsturcturemay be injuredwhen blunt orpenetrating injury isdelivered to the ribcage,and peritoneallavage becomes usefulin evaluating this are ofanatomy. 9. PelvisSurrounded by pelvicbonesUrinary bladderUrethraSmall bowelReproductive organsIliac vesselsLower part ofretroperitoneal spaceRectum 10. RetroperitonealAbdomenPotential space,Behind true peritonealcavity, contents areKidneysUretersPancreasDuodenum exceptpyloric partAscending anddescending colonAbdominal AortaInferior vena cava 11. Retroperitoneal abdominInjury to these sturucters may occur secondaryto penetrating or blunt trauma.The kidneys maybe damaged by injury to the lower ribsposteriorly,crushing injuries to the front,or sidesof the trunk may damage any of thesestructures.As with the thoracic and pelvicabdomen,injury to these sturctures may resultin few physical findings, and physicalexamination and peritoneal lavage may be oflittle, or no help. Evaluation of theretroperitoneal abdomen requires utilization ofradioghraphic procedures like i/vpyelography,angiography,and CT. 12. True abdomenThe true abdomen containsthe small and largeintestines, the bladderwhen distended, anduterus when gravid. Injuriesto any of these organs areusually manifested by painfrom peritonitis and areassociated with abdominalfindings. Peritoneal lavagea useful adjunct when aninjury is suspected, and aplain abdominal film whenfree air is present. 13. Classification of injuriesBlunt traumaPenetratingtraumaIatrogenic trauma 14. Blunt trauma;Mechanism ofinjuryA force to the abdomen thatdoesn't leave an open wound.Crushing injury, solid organmore vulnerable.(Deceleration injuries:differential movements of fixedand non-fixed structures (e.g.liver and spleen laceration atsites of supporting ligaments).External compression(seatbelt syndrome), whether fromdirect blows or from externalcompression against a fixedobject (e.g., lap belt, spinalcolumn),it causes sudden risein intra abdominal pressureand culminate in hollowviscous organ injury. 15. Pattern of Injury in Blunt Abdominal Traumaspleen 40.6% pancrease 3%kidney 12% Diaphragm 3%intestine 15% Urinary bladder 6%liver 15% urethra 2%Retrperitonealhaematoma13% vascular 2%Mesentery 5% stomach 1.3% 16. Common causes of bluntinjuryMost common causes: MVA (50- 75% of cases) blows to abdomen (15%) falls (6 - 9%) 17. Hollow and solid organs The type of injurywill depend onwhether the organinjured is solid orhollow. hollow organsinclude: Stomach Intestines Gallbladder Urinary bladder Uterus (female) Solid organs Liver Spleen Pancreas Kidneys Adrenals Ovaries(female) 18. Hollow organ injurieswhen hollow organs rupture,their highly irritating andinfectious contents spill into theperitoneal cavity, producing apainful inflammatory reactioncalled peritonitis 19. Solid organ injuriesDamage to solid organssuch as the liver cancause severe internalbleedingblood in the peritonealcavity causes peritonitiswhen patients injuresolid organs, thesymptoms of shock mayovershadow those fromperitonitis 20. Penetrating traumaEnergy imparted to bodyLow velocity: (distance ismore than 7 yards)Knife, icepickMedium velocity: (distanceis 3 to 7 yards)Gunshotwounds, shotgun woundsHigh velocity: (whendistance is less than 3yard)High-power huntingrifles, military weaponsBallisticsDistanceTrajectory 21. Penetrating abdominal trauma due toGSWSmall bowel (50%)Colon (40%)Liver (30%)Abdominal vascularstructures (25%) 22. Penetrating abdominal trauma due tostab woundLiver (40%)Small bowel(30%)Diaphragm(20%)Colon (15%) 23. Iatrogenic abdominaltraumaEndoscopic proceduresExternal cardiac massagePeritoneal dialysisParacentesisPercutaneous trashepaticcannulationLiver biopsyBarium enema 24. Pre hospital careLittle can be done for the patients with abdominalinjuries in the field.General features of stabilization and evaluationinclude ensuring an adequately functioning airway,inserting i/v lines in upper extremity, and beginningof fluid resuscitation.For penetarting wound sterile dressing should beapplied.Any foreign body embedded in the trunk shouldnot be removed, as major bleeding may follow.Evisceration is best left undisturbed,except toapply a sterile dressing and protect the patientfrom further injury.Proper positionEarly rapid transport 25. Hospital care and diagnosis Dx; requires history, examination,investigation History; Primary goal is to identify that injuryexists, not necessary making an accurateDx History from prehospital care, ortransferring team; vital signs, physicalassessment, prehospital course, andresponse to therapy should be obtained. Mechanism of injury is important factor inmaking high index of suspicion, so detailedhistory is helpful if available. 26. History contd In case of blunt trauma, determine The types of vehicles involved The speed they were traveling Collision patterns Use of seatbelts Air bag deployment The patients position in the vehicle In case of penetrating trauma by gunshot,determine Type of weapon used Number of shots Distance from victim 27. History contdsymptomsBack pain associated with compression fractureof the upper limbs or spinal region carries anassociated 20% chance of renal injury.Associated symptomsPain, vomiting, hematuria, hematochezia,dyspnea, respiratory distress.Thus in combination with the aspects ofphysical diagnosis and adjuncts to physicaldiagnosis as discussed below,assists in the initialassessment of abdominal injury.If the patient has sustained rib fracture on thelower left chest, there is a 20% chance ofassociated splenic injury,and with rib fracture onthe right there is 10% chance of liver injury. 28. ResuscitationThe ABCDE should be initiated.Patent air way, if necessary ETT with assistedventilation should begin particularly incomatose patients.Upper extremity,large bore i.v cannulae andi.v fluids with RL should begin immediatelyNext, perform a rapid neurologic examinationand assess him head to toeto identify obvious injuries and signs ofprolonged exposure to heat or cold.If your patient sustained blunt trauma, as in a motorvehicle crash (MVC), keep his neck and spineimmobilized until X-rays rule out a spinal injury. 29. ResuscitationVitals monitoringBlood sampling,forhematologic,biochemical,serologic investigationsshould be carried out.Abgs,and are repeated to assess ventilatorystatus and acidosis.Control the patients pain without sedating him, soyou can continue to assess his injuries and ask himquestions. Generally, I.V. analgesics such asmorphine can adequately manage pain withoutsedation.An early rapid assessment of the abdomen isperformed. 30. ResuscitationInsert an indwelling urinary catheter, unless yoususpect a urinary tract injury. For example,bloody urine or a prostate glandfound to be in a high position duringa rectal exam could indicate damage to theurinary tract.If the patient is to have a rectal examination,delay catheter insertion untilafterward.If urethral injury is ruled out,u.catheter isplaced, and sample of urine is taken to check formicroscopic heamaturia. 31. Insert a gastric tube to decompress the patientsstomach, prevent aspiration, and minimize leakage ofgastric contents and contamination of the abdominalcavity. This also gives you access to gastric contentsto test for blood, the presence of blood becomesindication for operation in penetrating trauma.Administer tetanus prophylaxis and antibiotics asordered. 32. Physical ExaminationInspection, palpation, auscultation,percussion,Inspection: abrasions, contusions,lacerations, deformity, entrance and exitwounds to determine path of injury.Grey-Turner, Kehr, Balance, Cullen sign palpation: elicit superficial, deep, orrebound tenderness; involuntarymuscle guardingPercussion: subtle signs of peritonitis;tympany in gastric dilatation or free air;dullness with hemoperitoneum.Auscultation: bowel sounds may bdecreased(late finding). 33. Physical Exam:EponymsGrey-Turner sign:Bluish discoloration of lower flanks, lower back; associatedwith retroperitoneal bleeding of pancreas, kidney, or pelvicfracture.Cullen sign:Bluish discoloration around umbilicus, indicates peritonealbleeding, often pancreatic hemorrhage.Kehr sign:L shoulder pain while supine; caused by diaphragmaticirritation (splenic injury, free air, intra-abd bleeding)Balance sign:Dull percussion in LUQ. Sign of splenic injury; bloodaccumulating in subcapsular or extracapsular spleen. 34. Seat belt sign 35. Cullans sign 36. Grey Turners sign 37. Physical examinationcontd..Assess for pelvic stability,supra pubic tenderness,pelvic lateral wall tenderness are assessed for pelvicfracture.Penile, vaginal, perineal, and rectal evaluationshould be done, and sphincter tone is checked.The integrity of rectal wall. the position and mobilityof the prostate are evaluated, and the examiningfinger should be tested for occult or gross blood. 38. Interpretation of physicalfindingsIntraperitoneal injuries can occur invascular,solid,and hollow organs. Interpretationof the physical findings associated with thesedifferent structures is often a function of theamount of the time that each of these types oforgans requires to create peritoneal irritation.The spectrum of injury can vary from a patient withrapid intra-abd bleeding,sec to a mesenteric arterylaceration, with no physical finding except forhypovolaemic shock,to a patient with immediateperitoneal irritation from inflammation injury tostomach or colon.Small bowel injury may not produce significant intra-abdfindings for 24 hours.So frequent re-evaluation becomes an essentialcomponent of any management protocol that is shortof definitive diagnosis. 39. Radiological and Ancillarydiagnostic proceduresPlain x-raychest,abdomen,andpelvisFastDiagnostic peritoneallavageContrast studies, CTscan.UrethrographyCystographyIvuAngiography 40. ImagingPlain films;In blunt trauma, fracturewith associated visceralinjuryIntraperitoneal free airRetroperitoneal stipplingassociated duodenalinjuryLoss of psoas shadowindicating retroperitonealbleedingIn penetrating trauma,injuring trajectory 41. AngiographyTo embolizebleeding vessels orsolid visceralhemorrhage fromblunt trauma in anunstable pt.Rarely fordiagnosingintraperitoneal andretroperitonealhemorrhage afterpenetratingabdominal trauma 42. Angiography andembolizationinitial angiogram PostembolizationRight iliac angiogram: acute extravasation(left) from the right superior and inferior lateralsacral arteries. Post-embolization (right)showing no evidence of acute arterial bleeding 43. Focused assessment withsonography for trauma (FAST)To diagnose free intraperitoneal fluid.Evaluate solid organ hematoma4 areas:Perihepatic & hepato-renal space(Morrisons pouch)PerisplenicPelvis (Pouch of Douglas/rectovesicalpouch)Pericardium (subxiphoid)sensitivity 60 to 95% for detecting100 mL - 500 mL of fluidExtended FAST (E-FAST):Add thoracic windows to look forpneumothorax.Sensitivity 59%, specificity up to 99% forPTX (c/w CXR 20%) 44. FastMorrison pouch 45. FastPerisplenicview 46. FastRetrovesicle, and pericardium(subxiphoid)views 47. FastAdvantagesPortable, fast (100,000MLWBC >500/MLAMYLASE 175U/DLALK PHOS >3IUBILE CONFIRMEDNEGATIVE RBC 75% circumference of D2, orinvolving the ampulla or distal common bile duct(V) Massive disruption of the duodenopancreaticcomplex or devascularization of the duodenum 84. Intraoperative evaluation ofduodenumComplete mobilization of duodenum(kochermanoeuvre)Hepatic flexure is taken down to expose the anterioraspect of 2nd part, and inspection of 3rd and 4th part atthe base of transverse colon.Retroperitoneal haemotomas in the areas mustexplored and lesser sac should be entered to excludeassociated pancreatic injuriesLimited perforations or simple lacerations are treatedwith primary closure within 6 hours, after that chanceof leak increasesSuction decompression with transpyloric NG,tubejejnostomy or tube duodenostomy is advisable ifrepair is any way compromised. 85. Duodenum injuriesIf laceration of the ist and 2nd portion of duodenum isextensive,and primary closure is associated withobstruction, Roux-en-Y jejunoduodenostomy is indicated.Another option is pyloric exclusion, in which proximalduodenum is defunctionlized by closing the pylorus, anddoing gastrojejunostomy.wounds of first and 2nd portion ofduodenum are closed primarily, and duodenum is drainedwith tube duodenostomy.The distal duodenum can be primarily closed if injury istreated within 6 hours, more than 6 hours ,or when there isextensive maceration resection of distal duodenum andduodenal jejunostomy should be performed.Grade v needs pancreaticoduodenectomy.Hematomas treated with NG suction until peristalsisreturns and slow introduction of solid foods,persistantobstruction require operative treatment. 86. Duodenal Hematoma 87. Post opt complicationsBleedingDuodenal fistula, occurs in 5-10% of the patientswhich unlike gastric fistula is managed non-operatively,with Ngsuction,nutritional support, andaggressive stoma care, and antibiotics if infection,uncomplicated fistulas will close in 6weeks,persistance beyond 6 weeks indicateoperative management 88. Pancreatic injuriesThe pancreas, because of its protectedretroperitoneal location, is less commonly injured.However, penetrating abdominal trauma accounts for70-80% of pancreatic injuries, and mortality ratesexceed 30%. Most pancreatic injuries are diagnosedintraoperatively. Pancreatic duct status and injurylocation are determinants in the management ofpancreatic injuries.Associated with other retroperitoneal tissue injury,mostly with duodenumElevation of serum and urine amylase following blunttrauma not diagnostic, but persistent elevationsuggests pancreatic injuryContrast duodenography may reveal widening of c-loop,loss of psoas shadow, ant displacement ofstomach and duodenum from pancreatic 89. Grades of pancreatic injuriesProximal injuries are to the right of the mesentericvessels, while distal injuries are to the left. Proximalinjuries are managed by closed suction drainage only.Distal pancreatic traumas with duct involvementundergo distal pancreatectomy and closed suctiondrainage.Pancreatic injuries are graded according to thepresence or absence of ductal injuries, as follows:(I) Superficial laceration or minor contusion withoutductal injury(II) Major laceration or contusion without ductal injury(III) Distal transections without duct injury or tissueloss(IV) Proximal transection or parenchymal injuryinvolving the ampulla 90. Pancreatic injuriesmanagementAfter hemorrhage is controlled and the pancreas isexposed, the extent of the injury, and associated duodenaltranverse mesocolon,trauma to stomach and spleen mustbe identified. Debridement must be selective to preserveas much endocrine and exocrine function as possible.Grade I and II injuries may need simple d.d with orwithout drainge.but grade III injuries are best treated withdistal pancreatectomy and splenectomy. Grade IV injuriesrequire near total pancreatectomy with reconstruction ofpancreatic drainage into the gastrointestinal tract witheither Roux-en-Y pancreaticojejunostomy orpancreaticogastrostomy. If the patient is too unstable,wide drainage of pancreatic tissue without anastomosismay be necessary. Grade v needspancreatoduodenectomy.wide drainage is the rule.Post opt complication include pancreatic fistula 91. Small bowel injury15-20% of patients who require laparotomy after blunttrauma, and 25-30% after penetrating trauma.Dx is often directly apparent secondary to peritonealinjury, or indirectly due to bleeding.At operation, after bleeding control, non-crushing clampsmust be applied to prevent further leakage of small bowelcontents.The small bowel should be carefully examined fromligaments of triets to ileocecal valve.Contusion of antimesenteric wall my result in delayedperforation, and seromuscular sutures can be used toimbricate the contusion into the lumenMesenteric haemotoma extending the bowel should beincised and evacuated.Single holes from stab wounds,or shotgun pellets can beclosed without debridement. 92. Small bowel injuriesTwo adjacent holes can be connected across thebridge of bowel and trasverse closure effected, so asnot to narrow the lumenLarge lacerations are debrided and closedTransection is debrided and closed in routine fashion,and mesenteric defect should be closedAny large segment that are devascularized ,ormultiple defects, should be resected,and re-anastomosed.Patients are maintained on post opt Ngdecompression until bowel sounds returnComplications are,i/abd abscess,anastomoticleakage,enetrocutaneous fistula, intestinal obstruction 93. Injuries to colon andrectumMostly penetrating injuries 17%,out of which 95% by stabwounds,gunshot,shot gun, blunt 5%Rectal injuries can occur in association with pelvicabdomen traumaS/S are not specific, indirectly will produce peritonealirritation and tenderness,DPL is of valve whenintraperitoneal part is involved.DRE shows blood and suggestive of colonic and rectalinujry.therefore proctoscopic and sigmoidoscopicexaminations should be performedPrimary repair can be selected when known associatedcomplication factors have been exluded, which arePre-opt hypotension,intraperitoneal hemorrage exceedingone litre,more than two associated organsinjure(hepatic,pancreatic, and splenic injuries aredangerous) 94. Colon/rectum injuries repairSignificant fecal spillage, or more than 6 hours havebeen elapsedLow risks patients should be treated with primaryclosure or resection and primary anastomosisHigh risk patients should be treated with resectionand colostomyPost-opt complications,abscess,anastomoticleak,parastomal hernia, and morbidity and mortalitywith colostomy closure.Rectal injuries must be suspected when there ispenetrating injury, sacral fracture, that produces pelvicring disruption.Sigmoidoscopic examination is essential 95. Principles of operative managementfor rectal injuriesPlacement of patient in the lithotomy position forproper exposureWide debridement of all dead and devititalized tissues.Totally defunctioning colostomyRectal wall closure, if possibleRetrorectal drainage with coccgectomy,whennecessary to attain adequate rectal drainageAntibiotics, nutritional support, and repeat debridementComplete rectal destruction requires APRComplications arePelvic abscessUrinary or rectal fistulas, rectal and urinaryincontinence, and strictureLoss of sexual function 96. RetroperitonealhaematomasCan be divided into 3 anatomical regionszone 1 includes pancreaticoduodenal injuries, majorabdominal vascular (aorta,vena cava) injuryZone 11 includes flank area,perinephric haemotomas,genitourinary tract injuries, and colon.Zone 111 are confined to pelvisRetroperitoneal haemtomas in Zone 1 are exploredregardless of aetiology,or size,Retroperitoneal haematomas caused by the penetratingmechanism should be routinely explored, the onlyexception to this rule would be those located in Zone 11which should be explore only if;They are adjacent to colon, and may be concealing anoccult colonic injury.They are expandingPre opt evaluation with ct has demonstrated a major renalinjury, that is amenable to repair. 97. Retroperitoneal haematomsZone 11 RH are mostly managed non-operatively, likerenal injuries with urine extravasation, if urinoma developsit can be managed with percutaneous drainage.Proximal control of renal pedicle should be gained in anyexploration of perinephric haematoma.Zone 11 blunt injuries can be left alone if they are notexpanding, or if ct, ivu is normal.Zone 111RH are generally explored in patients withpenetrating trauma in order to explore major vascular orureteral injuries, and local bleeding is easy to controlZone 111 RH in patients with blunt trauma haveassociated pelvic fratures,and exploration of thehaemtoma can be hazardousThere is often extensive injury to the rich presacralvenous and arterial circulation, incision to the peritoneumdestroys the tamponade effect, and dissection in thehematoma may produce catastrophic bleeding.Exploration of this haemtoma is associated withincreased transfusion requirement and high mortality ,asdiscrete bleeding points can rarely be identified. 98. Management of pelvicfracturesPelvic fractures is the major cause of mortality andmorbidity in pts with blunt abdominal trauma.MvA and pedestrian account for the majority of theseinjuries with mortality b/w 10 and 25%Massive haemorrhage and coagulopathy accountsfor 40-60% of mortality in this group of patients.Classification of pelvic fractures by trunkeyType 1 injuries represent crush fracture of the pelvisand involve three or more elements of the pelvic ring.Type 11 injuries are unstable injuries and involveatleast two breaks in the pelvic ringType 111 are stable fractures involving singleelement in the pelvic ring,or fracture of pubic rami. 99. Pelvic fractures 1,11,111 100. Pelvic fracturesThe initial management of patient with pelvic willdepend on associated injuriesIn patients with severe pelvic fractures who arehaemodynamically unstable,intracavitaryhaemorrhage must be excluded by radiological andDPL.The incidence of false+ results are high due to freedissection of blood from the pelvis into abdominalcavity and passage of lavage catheter into expandedpreperitoneal space, it can be minimized byperforming DPL through supra-umblical incision.Laparotomy is performed with positive lavage,intraabdominal injuries are treated and pelvic haemotomais not explored 101. Pelvic RH bleeding controlmethodsControl of ongoing pelvic RH bleeding is a challenge,both arterial and venous bleeding may be present,and patient may loss 20units of blood, methods tocontrol are given below;Application of military antishock trousers(MAST)(fieldand hospital resuscitation)Pelvic arteriography and arterial embolization(iftransfusion requirement exceed 4-6 units within first 2hours following injury)Early reduction of pelvic fracture using external pelvicfixation(open book fracture) 102. kidneysHigh on posterior wall of abdominal cavity inretroperitoneal spaceHeld in place by renal fasciaCushioned by layer of adipose tissuePartially protected by lower rib cageKidney most commonly injuredInjury often due to direct blows to back or flankChildren more susceptible than adultslessperirenal fat/rib cage less ossifiedPreexisting renal anomalieshydro, pujobstruction, tumors, abnl position (incidence 1-5%) 103. Renaltrauma 104. Renal injuries treatmentGrade I-III renal injuries can often be observedGrade IV and V renal and lower urinary tractinjuries often require surgery, and it involves partialnephrectomy, or radical nephrectomy. 105. Ureteral injuriesUncommon, occurs mostly with penetrating trauma.The presence of haematuria is not a consistentfindingSuspected pre-opt by the location of penetratinginjury, or in case of blunt trauma, by the presence ofconcomitantInjury or other genitourinary tract injuries.In 80-85% IVP will confirm, but in 15-20% requireretrograde ureterography.In unstable patients diagnosis of ureteral injury maybe made at the time of laparotomy by chromo-ureterography.This procedure is carried out by the intravenousinjection of 5ml of methylene blue, extravasation of 106. Surgery According to ureteric injuryFor upper third of ureteral injury,uretero-ureterostomy,in case of extensive ureteralloss,auto-transplanation of kidney into iliac fossa.For middle third injuries, reimplanatation ofdamaged ureter in to normal ureter across themidline, or renal or bladder mobilization to allow fortension free anastomosis.For lower third injuries creation of anterior bladderflap tube into which a shortened ureter may bereimplanted. 107. Urinary bladderMajority are blunt external trauma, suspected inpatients with haematuria and pelvic fractures.Bladder rupture may be extra peritoneal orintraperitoneal.Extra peritoneal rupture is perforation by adjacentbony fragment in pelvic fracturesIntra peritoneal rupture mainly of dome of bladder asa result of direct blow to distended bladder.Dx is made by cystography,IVP is often necessary toevaluate the upper urinary tract.T/M of I/P rupture includes suprapubic cystostomywith drainage 108. Bladder injuriesThe management of extra peritoneal is primarilynon-operative by the use of Foley catheter drainagefor prolonged period of time, requires that the patienthas no other intra-abdominal injuries, no significantlocal haemorrhage,and no urinary tract injury.When associated with above mentionedcomplications, delayed repair can be done whenretroperitoneal bleeding is controlled and theircondition stabilized.Complication rate is 20-25% and even more withnon-operative management 109. Injuries to urethraDisruption of the urethra is found mostly in pelvicfractures, in males only, so called straddle injury.Posterior urethral tears are present in 10% ofpelvic fractures.Urethral injuries are suspected on the basis ofmechanism, associated pelvic fractures,perinealinjury, blood at the urethral meatus,anddisplacement of prostate gland.Dx is made by retrograde urethrogram.T/M is suprapubic cystotomy and delayed urethralrepair.Delayed repair has served to markedly diminish theincidence of striture,impotence,and incontinence . 110. Complications of genitourinarytrauma Early complications are Hemorrhage Urinary extravasations Infection Late complications Hypertension, AV fistula and pyelonephritis withrenal injuries Stricture formation and hydronehrosis withureteral transections Stricture incontinence and impotence withurethral ruptures 111. Abdominal compartmentsyndrome Trauma patients with severe intra-abdominalinjuries, presenting in profoundshock and requiring large amounts ofintravenous fluids are those mostsusceptible to the development of suddenincrease in intra abdominal pressure. This syndrome is characterized byabdominal distension,oliguria,hypoxia,andincreased pulmonary pressure. The diagnosis is confirmed by themeasuring the intra abdominal pressuredirectly or the intravasical pressure. Types are primary and secondary 112. Pressure values Abdominal pressures over 20 mmHg Abdominal perfusion pressures (APP)less than 50mmHg Abdominal perfusion pressure equalsthe mean arterial pressure minus theabdominal pressure. (MAP ACP =APP) 113. Normal values At rest 0 5mmHg Valsalva 60 80mmHg Cough 80cmH2O Vomiting 60cmH2O Active lifting Over 150mmHg During lifting the pressure is related tothe velocity of muscle contraction andcomes back to baseline once themovement has ended 114. ACS grading Grade I 10 15mmHg Grade II 16 - 25mmHg Grade III 26 35mmHg Grade IV >35mmHg 115. Constellation of Symptoms Renal failure Decreased urine output Respiratory failure Dec compliance, inc pulmonary edema / airwaypressure Cardiac failure Decreased cardiac output (dec preload / inc afterload) Visceral failure Dec blood flow to liver, bowel (bacterialtranslocation) Neurologic complications Increased intracranial pressure Abdominal wall failure Dehiscence, hernia formation 116. ACS management Surgical abdominal decompression Nonsurgical: paracentesis, NGT, sedation Staged approach to abdominal repair Temporary abdominal closure 117. Summary Mechanism of injury Blunt vs. Penetrating ABC Stability of trauma patients Select appropriate diagnostic imaging Think about associated injuries Multi-modality Clinical FAST CT Scan Interventional Radiology Surgical exploration 118. Thank you