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Saving Lives By Strengthening Our Regions Trauma Care System December 5, 2013 MICHAEL SLOAN, MD CASE STUDIES IN ABDOMINAL TRAUMA Slide 2 WHEN TRAUMA IS OBVIOUS Slide 3 NO IMAGING IS NECESSARY Slide 4 WHEN TRAUMA IS UNCERTAIN Slide 5 TROUBLE LURKS JUST BELOW THE SURFACE Slide 6 TRAUMA Leading cause of death ages 1-44 years in most developed countries Motor vehicle crashes account for the majority of injuries and deaths in 70% of the 39 countries for which data is available 60 million injuries estimated in the US each year, resulting in 36.8 million ER visits Slide 7 TRIMODAL DEATH DISTRIBUTION Slide 8 ABDOMINAL TRAUMA Multiple Mechanisms of Injury 1.Crushing direct application of blunt force 2.Shearing sudden deceleration of organs with fixed attachments 3.Bursting increased intraluminal pressure from abdominal compression 4.Penetrating knife/gun/stick/bone Slide 9 INJURIES Solid organ Hollow viscus Diaphragm Retroperitoneal Vascular Genitourinary Pelvic Slide 10 YOUR TOOL KIT Slide 11 YOUR DESTINATION Slide 12 CASE #1 History 72 year old male status post auto versus bicycle No LOC (wearing helmet) Complaint of rib pain, hip pain, and lower extremity pain on arrival Level 2 Trauma activation GCS 15, HR 88, BP 138/66, RR 14, O2 sat 98% 2L NC Slide 13 INITIAL ASSESSMENT Airway Breathing Circulation Disability Exposure Working Diagnosis Rib fracture Low back pain Hip/Femur fracture Slide 14 INITIAL IMAGING Slide 15 WHILE AWAITING CT HR 114, BP 114/60, RR 20, O2 sat 98% 2L NC Patient complaint of need to void I cant pee! Nausea => Emesis Foley placed amber urine ( 4. ARE THERE RADIOLOGIC FINDINGS WHICH PREDICT HEMORRHAGE? Fracture pattern on pelvic X-ray does not single-handedly predict mortality, hemorrhage, or the need for angiography. Level II recommendation Presence/location of hematoma does not predict or exclude the need for angiography and possible embolization. Level II recommendation CT of the pelvis is an excellent screening tool to exclude pelvic hemorrhage. Level II recommendation Absence of contrast extravasation on CT does not always exclude active hemorrhage. Level II recommendation Pelvic hematoma >500 cm in size has an increased incidence of arterial injury and need for angiography. Level II recommendation Isolated acetabular fractures are as likely to require angiography as pelvic rim fractures. Level III recommendation If a retrograde urethrocystogram is required, it should be performed after CT with intravenous contrast. Level III recommendation Slide 31 5. WHAT IS THE ROLE OF NONINVASIVE TEMPORARY EXTERNAL FIXATION DEVICES? TPBs effectively reduce unstable pelvic fractures as well as definitive stabilization and decrease pelvic volume. Level III recommendation TPBs may limit pelvic hemorrhage but do not seem to affect mortality. Level III recommendation TPBs work as well or better than emergent EPF in controlling hemorrhage. Level III recommendation Slide 32 6. WHICH PATIENTS WARRANT PREPERITONEAL PACKING (PPP)? Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as a salvage technique after angiographic embolization. Level III recommendation Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway including a POD/C-clamp. Level III recommendation Slide 33 Slide 34 CASE #2 History 49 year old female passenger, restrained, MVC Possible brief LOC Complaint of left chest/breast pain, mild right abdominal pain Level 2 Trauma activation GCS 15, HR 71, BP 154/94, RR 20, O2 sat 100% 6L Slide 35 INITIAL ASSESSMENT Airway Breathing Circulation Disability Exposure Working Diagnosis ?LOC Breast pain Abdominal pain (mild) Slide 36 INITIAL IMAGING Slide 37 WHILE IN CT Increased agitation = CT head negative GCS 14, HR 77, BP 51/35 CT chest/abd/pelvis in progress Slide 38 Slide 39 WHILE IN CT Scan stopped, IV bolus provided HR 74, BP 102/52 Delayed images show increased free fluid HR 74, BP 88/40 Taken to OR from CT scanner for exploration Shearing injury of abdominal wall Avulsion of 30 cm of distal ileum requiring resection Active bleeding from branch of ileocolic artery Slide 40 Slide 41 BLUNT VISCERAL INJURY Sir McCormack in 1900 was the first to advocate A man wounded in war in the abdomen dies if he is operated upon and remains alive if he is left in peace Nonoperative Management has reported success rates of ~90% in properly selected patient populations regardless of age, grade of injury, multivisceral injury, and mechanism of injury Slide 42 Slide 43 Slide 44 Slide 45 Slide 46 FAST, DPL, DIAGNOSTIC LAPAROSCOPY Overall, FAST has a sensitivity between 73% and 88%, a specificity between 98% and 100% and is 96% to 98% accurate The accuracy of DPL has been reported between 92% and 98% Although there are no randomized, controlled studies comparing Diagnostic Laparoscopy (DL) to more commonly utilized modalities, experience at one institution using minilaparoscopy demonstrated a 25% incidence of positive findings on DL, which were successfully managed nonoperatively and would have resulted in nontherapeutic laparotomies Slide 47 OTHER ITEMS OF INTEREST Damage Control Surgery Abdominal Compartment Syndrome Slide 48 DAMAGE CONTROL Traditional thinking = The best operation for a patient is a single, definitive procedure ER => OR => ICU Unfortunately, severely injured patients (ISS>35) are more likely to die from intra- operative metabolic failure, than from failure to complete a definitive procedure Slide 49 DEATH TRIAD Hypothermia AcidosisCoagulopathy Slide 50 OR POSSIBLY A LITTLE MORE COMPLEX Slide 51 DAMAGE CONTROL IN PRACTICE Control hemorrhage Contain/Stop contamination Avoid further injury ER => OR => ICU => OR => ICU Slide 52 GUIDELINES FOR INSTITUTING DAMAGE CONTROL pH < 7.2 Serum bicarbonate < 15 Core temp < 34 C Transfusion > 4 L pRBC Total blood products > 5 L Total fluid > 12 L If all of the above = death If one or more = damage control Slide 53 ABDOMINAL COMPARTMENT SYNDROME https://www.wsacs.org/ Slide 54 Slide 55 Slide 56 QUESTIONS