thesis discussion: "evaluation of different modalities of management of penetrating abdominal...

بسم الله الرحمن الرحيم

Evaluation of different modalities of management of penetrating

abdominal trauma in Kasr Alainy emergency department

Mohamed Mostafa AlasmarMBBCh

Aim of work

• Our aim is to evaluate different modalities of management of penetrating abdominal trauma and to assess their effectiveness in the management of our patients.

• Furthermore, the validation of our current management strategy and recommendations for the future.

Penetrating Abdominal Trauma

Anatomy

Mechanisms of penetrating trauma

• Low energy-knife (stabs)• Medium energy-handguns (shotgun)• High energy-military or hunting rifles

(gunshot)

Stab wounds

• Wound size and type of weapon are very important although they do not necessarily correlate with the depth of wound or trajectory.

Gunshot

Missile with large cross-sectional front such as hollow-point bullets that spread or "mushroom" on Impact, cause more injury and cavitation

Gunshot

The AK-47 rifle is one of the most common weapons seen throughout the world. For this particular bullet (full metal jacketed or ball), there is a 25 centimeter path of relatively minimal tissue disruption before the projectile begins to Yaw. This explains why relatively minimal tissue disruption may be seen with some wounds

Velocity

• The velocity of a missile is the most significant determinant of its wounding potential.

• Kinetic Energy = mass x (V12 – V22)/2

Where V1, is impact velocity and V2, is exit or remaining velocity

Shotgun

• Shotgun pellets separate after leaving the barrel of the gun and their velocity rapidly decreases. As the pellets spread with increasing range, their area of distribution increases and the energy in each pellet decreases.

• Can carry clothing and deposit wadding into the depth of the wound and become a source of infection if not removed.

Blast injuries

Assessment and management of trauma patient

• Resuscitation of the trauma patient requires an organized, systematic approach utilizing a well-rehearsed protocol.

• Advanced Trauma Life Support (ATLS®) developed by the American College of Surgeons – Committee on Trauma in 1978.

Assessment of patient’s Abdomen

Clinical examination

• Inspection, palpation, percussion and auscultation.

• Searching for evidence of bleeding, air or peritoneal irritation.

Different modalities in management of penetrating abdominal trauma

Aim of these modalities

• Diagnostic vs. therapeutic. • Diagnostic:

– Imaging modalities including: Chest x-ray, FAST and CT scan.– DPL– Detection of the violation of peritoneum: LWE and Diagnostic

laparoscopy.– Serial physical examination.

• Diagnostic and therapeutic:– Formal exploration and laparoscopic exploration

• Innovations:– Laparoscopic diagnostic peritoneal lavage. – Awake laparoscopy (under LA).

Patients and methods

• This is a prospective study of 50 patients presented to Kasr Alainy emergency room with penetrating abdominal trauma in the period from 1st of August 2012 to 1st of March 2013.

• Inclusion criteria: any penetrating wound that may injure intraabdominal organs.

• There was no exclusion criteria.• The management modalities chosen for each

patient were according to surgeon preference

Results

• The 50 patients included in this study were 48 males & 2 females, their age ranged between 16 and 54 years. The mean age was 27.5 years.

male96%

Female4%

16 19.8 23.6 27.4 31.2 35 38.8 42.6 46.4 50.2 54

0

2

4

6

8

10

12

14

16

6

7

15

13

3

1

2 2

0

1

Age

Fre

qu

en

cy

• All patients suffered from penetrating abdominal trauma in the form of stab wounds (36 patients), shotgun (12 patients) and gunshot (2 patients).

Gunshot4%

Stab72%

Shotgun24%

• Twenty one patients (42%) were found to be positive for intraabdominal injuries either by investigations or on exploration.

Yes42%

No58%

• All patients were subjected to clinical examination of the abdomen.

• Seven patients presented with eviscerated omentum (of which 5 cases were positive for injuries), 10 patients presented with acute abdomen (all of them were positive for injuries), 33 patients were asymptomatic and had no signs of peritoneal irritation (of which 5 cases were positive for injuries)

NegativePositiveevisceration

0

5

10

15

20

25

30

No

Yes

3D view of the contingency table

Rows

Columns

• Radiological investigations in the form of chest X-ray, FAST scan and CT abdomen were done according the decision of the consultant.

• The chest x-ray was found to be positive in 2 cases with air under diaphragm.

• FAST scan was done in 39 patients( 78%). The scan was negative in 29 patients (58%) and positive in 10 patients ( 20%)

• From the 29 negative cases there were 7 patients positive for intraabdominal injuries. All cases with positive FAST had indeed intraabdominal injuries. Therefore, the sensitivity of FAST in detecting intraabdominal injuries was 70.8%, while the specificity was 100%.

Not Done22%

Done - Negative58%

Done - Positive20%

• CT scan was done in (17 patients, 34%). The scan was negative in (4 patients, 8%) and positive in (13 patients, 26%).

• All 4 negative cases had no intraabdominal injury. There were intraabdominal pellets in 4 shotgun cases without intraabdominal injury. The sensitivity of the CT scan in detecting intra abdominal injuries was 100% and the specificity was 50%.

Done - Positive (mention in comments)

26%

Not Done66%

Done - Negative8%

• Diagnostic laparoscopy was done in 8 patients (16%). The DL was negative in 4 patients (8%) and positive in 4 patients (8%)

• No intraabdominal injuries detected in patients with negative laparoscopic exploration. Three cases out of the 4 cases with positive peritoneal penetration by diagnostic laparoscopy were found to have no intraabdominal injuries. That gives the diagnostic laparoscopy sensitivity of 100% and specificity of 57.14%.

Not Done84%

Done - Positive8%

Done - Negative8%

• Local wound exploration was done in 6 patients (12%) all of them were negative.

• All 6 negative cases have no intraabdominal injuries and there were no positive cases. All case were low energy stab wounds. LWE has 100% specificity.

Not Done88%

Done - Negative12%

• Exploratory laparotomy was done in 28 patients (56%). eighteen of them (36%) were positive, eight of them (16%) were negative. Two patients (4%) were explored after more than 24 hours of injury and were positive.

Positive36%

Negative16%

Not Done - Con-servative

44%

Delayed, Positive4%

• The mean hospital stay for the 50 patients was 2.66 days. • The mean hospital stay on conservative management was

1.76 • In patients after exploratory laparotomy positive for

intraabdominal injuries it was 3.58 days • After non-therapeutic laparotomy it was 2.57 days.

non-therapeutic laparotomy

Positive cases with

Exploratory laparotomy

conservative management

mean hospital stay

2.57 3.58 1.76 2.66

• Complications occurred in 12 patients (24%) all of them in the exploratory laparotomy group.

• No patient under conservative management had any complication.

• There were no complications in the non-therapeutic laparotomy group.

• Complications varied from surgical site infection in 8 patients, ICU admission in 4 patients mortality in 4 patients.

Discussion

FAST scan

• Our study supports that the FAST scan is a very specific tool in detecting intraabdominal injuries (100% specificity) as all positive cases detected by FAST scan had intraabdominal injuries on exploration.

• But care must be taken in cases with negative FAST scan as it has a relatively low sensitivity (70.8%).

• "rule-in" not "rule-out"

CT scan• Our results support the value of using CT scan

in detecting intraabdominal injuries in back and flank stabs

• Limited accuracy in detecting intraabdominal injuries in shotgun wounds even in the presence of intraabdominal pellets.

CT scan in shotgun injuries

• The presence of intraabdominal pellets on CT scan without obvious associated organ injury prompted us to use the CT scan in conjunction with frequent clinical examination in these cases to minimize the rate of nontherapeutic laparotomies, hospital stay and complications.

• However CT scan is a very good tool to rule out the presence of intraabdominal injuries in negative cases as its sensitivity was 100% in our study, which opens the possibility of discharging these patients from ED reaching a zero hospital stay.

Diagnostic laparoscopy

• Its use as the sole indication for laparotomy resulted in a high rate of nontherapeutic laparotomies.

• We think that this disadvantage could be overcome by combining the laparoscope with other diagnostic modalities. One such suggestion would be LDL (laparoscopic peritoneal lavage).

• Alternatively, the laparoscope could be extended to formally explore all intra-abdominal contents and even therapeutic intervention if warranted and the experience of the surgeon permits.

• Herewith, we can minimize the rate of nontherapeutic laparotomies and consequently, the hospital stay and rate postoperative complications.

LWE• In our study LWE was done in 6 patients (12%) all

of them were negative. This phenomenon seems to be related to the fact that surgeons at Kasr Alainy emergency department prefer the use of LWE in cases that most likely have no peritoneal penetration. This can be suggested by the history of trauma and description of the offending tool.

• we believe that the use LWE in cases who most likely have no peritoneal penetration as in low velocity penetrating injuries can rule out a good proportion of patients in a simple and low cost way.

• Although, we could not determine the specificity of LWE, we expect, that similarly to diagnostic laparoscopy it will have a low specificity as again it is used only to detect peritoneal penetration

• Unlike diagnostic laparoscopy, conservative management and frequent clinical examination after positive LWE is an option as LWE is performed under local anesthesia and not under general anesthesia like diagnostic laparoscopy which makes the clinical examination unreliable.

Serial clinical examination

• In our study all positive cases had intra-abdominal injuries. As for evisceration, it is not always the case.

• Relying on evisceration alone as evidence of presence of intraabdominal injury is not sufficient, as it is mainly a marker of violation of peritoneum like LWE and Diagnostic laparoscopy.

Hospital stay and complications

• Non therapeutic laparotomies per se prolong hospital stay.

• Not a single patient under conservative management suffered any complication.

• Interestingly, there were also no complications in the group of patients whose exploratory laparotomy proved non-therapeutic.

• Taking these findings into consideration puts forth that the most important determining factor for the occurrence of complications is the presence of intra-abdominal injuries rather than the exploratory laparotomy.

• Even though evidence from our study supports this on the short term, we can certainly not deny the long-term effect of exploratory laparotomies

Conclusion

• No single modality per se proved the ideal in all cases

• A combined approach using different modalities (clinical examination, FAST, CT scan, laparoscopic exploration and local wound exploration) in diagnosing intraabdominal injury, selected according the mode and site of injury, has significantly high sensitivity and specificity in the diagnosis of intraabdominal injuries

• These modalities reduced rate of negative laparotomies, mean hospital stay and complications.

Thank you..