Resuscitation & Abdominal trauma

Presenter : Muhammad AfifAnis Zarina

Supervisor : Dr Wazir

OutlineDEFINITION AND INTRODUCTION

ASSESSMENT & RESUSCITATION

DEFINITIVE CARE

TAKE HOME MESSAGES

DEFINITION AND INTRODUCTION

• TRAUMA – cellular disruption caused by environmental energy / physical force

• 6th leading cause of death worldwide(10% of cases)

• Leading cause of death in those aged 5 to 40 years

• Majority of trauma cases is due to road traffic accidents (70.1%)

Trauma related death has a trimodal distribution

A) Death due to massive injuries. Seconds to minutes.

B) Death due to hemorrhage. Hours.

C) Death due to late complications of trauma. Days to weeks.

*golden hour – in the 1st hour, 30% of death takes place

Lethal triad of death in trauma

Severe haemorrhage → hypovolemic shock → Hypothermia +

coagulopathy+ acidosis 3 factors aggravate each

otherin a vicious cycle → further bleeding → intractable shock→ death

Assessment and resuscitation•Primary survey with concurrent

resuscitation.•Requires a team of doctors, nurses,

assistant medical doctors and attendants.•Must be lead by a team leader.•Secondary survey with concurrent

resuscitation.•Reassessment and on going resuscitation

while reviewing investigations.

Primary Survey•A = Airway maintenance with cervical

protection – intubate if necessary.•B = Breathing and ventilation – Look for

signs of respiratory distress and SPO2. ▫Non invasive or invasive oxygen therapy

with relief of life threatening conditions eg tension pneumothorax.

•C = Circulation with hemorrhage control▫2 large bore 16 Gauge branula, CBD, CVP▫IV crystalloids 30ml/kg run fast▫Stop external bleeder▫Colloids and blood products.▫Aim MAP 65mmHg

•D = Disability ,neurological status•E = Exposure / environmental control

Evaluation of fluid resuscitation•The return of normal blood pressure,

pulse pressure and pulse rate•Improvements in CNS status and skin

circulation . •Urine Output : 0.5-1ml/kg/h•CVP•Acid base balance

▫Persistent metabolic acidosis is usually due to inadequate resuscitation or ongoing blood loss.

After fluid bolus is given..Rapid response Transient response No response

Vital signs Return to normal Transient improvement

Remain abnormal

Estimated blood loss

Minimal (10-20%) Moderate and ongoing (20-40%)

Severe (>40%)

Need for more crystalloid

Low High High

Need for blood Low Moderate to high Immediate

Blood preparation Type and cross match

Type – specific Emergency blood release

Need for operative intervention

Possibly Likely Highly likely

Need for immediate surgical intervention

No No Yes

Transient or non responder•Most common: ongoing internal bleeding

- clinically : more pallor, persistent tachycardic, tachypnea, abd distension- FAST scan- Aggressive fluid resuscitation (using 3:1 rule)- Blood transfusion : 2pint pack cell

*consider DIVC regime

Secondary Survey•Follows the primary survey•Complete history including AMPLE•Complete head -to-toe examination•Reassessment of response to

resuscitation.

ExaminationInspection Palpation Auscultation

Distended Tenderness Bowel sounds -absent -in thorax

Abrasion Guarding

Laceration Rigidity

Cullen’s, Grey turner’s, Kehr’s sign

Mass

Gross hematuria PR – high riding prostate

Hematoma or bruises

Cullen’s sign

Grey turner’s sign

Kehr’s sign

Investigations

•Serial FBC, RP, PT/INR, ABG, Serum amylase

•FAST US•X-ray chest and abdomen•USG Abdomen•CT scan

Focused Assessment with Sonography in Trauma (FAST)• To detect hemoperitoneum & pericardial effusion• Sensitivity 86- 99%• Four different views:

-Pericardiac -Perihepatic -Perisplenic -Peripelvic

Advantages of FAST• Can detect 100 mL of blood

• Rapid , accurate, portable, reproducible

• Cost effective, non invasive, no radiation

• Eliminates unnecessary CT scans

• Helps in management plan

Plain X-ray chest & AbdomenCXR:• Free air under diaphragm• NG tube or bowel loops in the thoracic cavity• Elevation of both or single diaphragm• Lower ribs fractures

AXR:• Ground glass appearance-massive

hemoperitoneum• Obliteration of psoas shadow-retroperitoneal

bleed

CT scan

•Gold standard •High sensitivity and specificity-95%•Provides excellent imaging of solid and

hollow organs, retroperitoneum, genitourinary system (able to grade) and hemo/pneumoperitoneum.

•Determines the source of bleeder.•Can reveal other associated injuries eg

vessels.•Only in haemodynamically stable patients.

ABDOMINAL TRAUMA

MECHANISM OF INJURY

Blunt trauma Penetrating injury

Fall from height Stab wound

MVA Gunshot wound

Domestic injury

Sport injury

Contact injury

Child abuse

Abdominal injuries•Intraperitoneal • Solid, hollow, mesentery

•Retroperitoneal•Abdominal wall (hematoma) esp in

warfarinized or hemophilia patients after minor trauma.

Intraperitoneal

•Solid organs▫Spleen(40-55%)▫Liver(35-45%)

•Hollow organs ▫Gastric, bowel, bladder or GB perforation▫Penetrating injury

•Mesentery (bowel ischaemia)

Retroperitoneal

•Pancreas (10-20%) – traumatic pancreatitis

•Vascular(5-10%) – major vessels•Kidneys(5%)

Indications for laparotomy

•Blunt abdominal trauma + hypotension + positive FAST or clinical evidence of intraperitoneal bleeding

•Penetrating trauma : eg : Gunshot or abdominal evisceration

•Peritonitis •Free air, retroperitoneal air or rupture of

hemidiaphragm after blunt trauma•Organ specific injury - on CT scan

Splenic injury•20% due to left lower rib fractures

Conservative Management:▫Hemodynamic stable▫Negative abdominal examination▫Absence of contrast extravasation in CT▫Subcapsular Hematoma, Laceration <3cm

•Serial abdominal examination and CT scan.•Success rate of conservative Mx >80%

Operative management

•Splenorrhaphy with serial monitoring.•Total Splenectomy and vaccination.•Success rate of splenic salvage procedure

is 40-60%.•Others – partial splenectomy, total

splenectomy with autotransplantation.

Liver injury

•Largest organ - 2nd most commonly injured

•85% with blunt hepatic trauma are stable•CT – main stay of diagnosis in stable

patient•Most treated conservatively•Watch out for on going bleed, hepatic

necrosis, infected billoma, biliary tree injuries.

Conservative management

•Haemodynamically stable•No other intra abdominal injury require

surgery•< 2 units of blood transfusion required in

6 hours•Hemoperitoneum <500ml on CT

Operative management

•Liver packing- Bleeding can be stopped- Pack removed after 48hr

•Pringle’s maneuver- Direct compression of the portal triad

(digitally or soft clamp) to control the inflow

• Lobar Resection •Liver Transplantation

Renal injury

•Clinically not suspected & frequently overlooked

•Clinical - Shock, hematuria & pain over the loin

•Urine: gross or microscopic hematuria•CT scan – Grading

Management

•85% of blunt renal trauma can be manage conservatively.

•Indications for nephrectomy▫Hemodynamic instability▫Grade 5 renal injury

•Risk of dialysis should be explained if planned for nephrectomy.

Take home messages• Primary survey and resuscitation goes

hand in hand. It’s an ongoing process.• Coagulopathy, hypothermia, and

worsening metabolic acidosis are lethat triad that need to be watched out for in trauma patients• Fluid resuscitation is vital and evaluation

of it is important.• Negative FAST scan cannot exclude

possibility of significant intraabdominal injury if clinically is indicated.

•CT scan is gold standard to diagnose intraabdominal injury in hemodynamically stable patient.

•20% of splenic injury is due to lower rib fractures

•85% with blunt hepatic trauma are stable•85% of blunt renal trauma can be manage

conservatively

References

•ATLS for Doctors, 9th edition•Bailey & Love Short Practice of Surgery,

25th edition•http://www.surgeons.org.uk/advanced-tra

uma-life-support/shock.html•Clinical companion in surgery

•Thank you!