RESUSCITATION AND ABDOMINAL TRAUMA PPS SITI NUREZZATI PPS FARAHIN SUPERVISOR: DR RAUF OUTLINE INTRODUCTION • Trimodal distribution of death ASSESSMENT & RESUSCITATION • Primary and Secondary Survey • Adjuncts of resuscitation • Recognition of abdominal trauma ABDOMINAL TRAUMA • Types of abdominal Trauma • Mechanism injury • Specific organ Injury TAKE HOME MESSAGES INTRODUCTION definition: an injury (such as wound) to living tissue caused by an extrinsic agent. -trauma is one of common reasons for death and hospitalization in Malaysia ( Journalarticleukm.com ‘epidemiology study of abdominal and pelvic injury trauma in post mortem cases at HKL 2008-2009’ 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 • Aggressive resuscitation during this time can greatly improve the chances of survival Lethal triad of death in trauma Severe haemorrhage → hypovolemic shock → Hypothermia + coagulopathy + acidosis 3 factors aggravate each other in a vicious cycle → further bleeding → intractable shock → death ATLS way of trauma management Preparation and Triage Definitive Care Primary Survey Reevaluation reevaluation Secondary Survey Constantly reevaluating traumatic patient is crucial to ensure that new findings are not overlooked and to discover deterioration in previously noted findings. ASSESSMENT AND RESUSCITATION PRIMARY SURVEY - Focused, quick and simple way in assessment of trauma patient. Aim: detect for 6 life threatening conditions 1. Airway obstructions 2. Tension pneumothorax 3. Open pneumothorax 4. Massive pneumothorax 5. Flail chest 6. Cardiac tamponade A: airway with cervical spine control -look for sign of airway obstruction -Intubation is indicated: 1. Poor GCS: <9 2. Severe maxillofacial fractures: laryngeal/tracheal injury 3. Hypoxia B: breathing -Assess breath sounds, chest percussion, chest wall excursion, and jugular venous distension. - By clinically can exclude life threatening conditions. • 3. circulation with hemorrhage control Assess for and stop external hemorrhage •Direct manual pressure •tourniquet Assess for tissue perfusion •Vital signs •Skin: color temp, CRT •Mental status •Urine: 1cc/kg/h Gain vascular access •Two large bore iv cannula (16 gauge) Fluid Resuscitation •IV crystalloid 20mls/kg •Penetrating trauma: “permissive hypotension” principles Assess for response D: Disability (neurological evaluation) • Level of consciousness: Glasgow Coma Scale • Pupil symmetry and reaction to light • Lateralizing signs and spinal cord injury level E: Exposure/environmental – Remove all clothing to facilitate access and examination. – Logroll maneuver to examine patient’s back. – Maintain normothermia. ADJUNCTS OF RESUSCITATION Investigations Laboratory Imaging others • • • • FBC Renal Profile and electrolyte Amylase Urine analysis • Xray (chest and abdominal) • FAST scan • CT scan • ECG • CBD • Ryles tube Focused Assessment with Sonography in Trauma (FAST) • To diagnose free intraperitoneal fluid • Sensitivity 86- 99% - the larger the freefluid the higher the sensitivity Pericardium (subxiphoid perisplenic Perihepatic& hepato-renal space(morrison’ s pouch) Pelvis (Pouch of Douglas/ rectovesical pouch) CT SCAN • Accurate for solid visceral lesions and its grading and intraperitoneal hemorrhage. • Sensitivity for solid organ is 95%, diaphragmatic 60% and pancreatic 30% • Reveal associated injuries. • Indications: FAST +ve and only hemodynamically stable patient • Contraindications: clear indication for exp laparotory, unstable patient. Indication of Laparotomy 1. Hypotension with penetrating abdominal wound 2. Evisceration 3. Bleeding of abdomen from penetrating trauma 4. Free air, retroperitoneal air or rupture hemidiaphragm Diagnostic peritoneal lavage(DPL) Is a surgical diagnostic procedure to determine if there is free fluid (most often blood) in the abdominal cavity. • Criteria for +VE DPL: 1. 2. • • 3. 4. Receive 10ml of gross blood Cell count: RBC >100,000 WBC > 500 Biochemistry: Amylase >175iu/ml Microscopic : food particle,bile, bacteria • no longer use nowadays due to presence of FAST scan and CT scan. RECOGNITION OF ABDOMINAL TRAUMA CLINICAL FINDING Inspection 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 ( Posterior uretheral rupture) Hematoma or bruises • Cullen’s sign • -bluish discoloration around umbilicus • -diffusion of blood along periumbilical tissues of falciform ligament • -hemoperitoneum/severe pancreatitis • Grey Turner’s sign • -bluish discoloration of the flanks • -retroperitoneal hematoma/hemorrhagic pancretatiis • Kehr's sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. • classic symptom of a ruptured spleen. • Seatbelt syndrome is defined as a seatbelt sign associated with a lumbar spine fracture and a bowel perforation • Lower rib fracture are associated with spleen and liver injury. MECHANISM OF INJURY Blunt trauma Penetrating injury Direct blow Stab wound Shearing/ deceleration injuries Gunshot wound ABDOMINAL TRAUMA Abdominal Truma Blunt Abdominal Trauma (BAT) Penetrating Abdominal Trauma (PAT) Solid Organ Gunshot/Evisceration Hollow Organ Stab Trauma Definition Blunt abdominal trauma refers to when abdominal organs are compressed against the backbone, or when internal structures are stretched at their attachments. Penetrating abdominal trauma typically results in direct injury to organs in the direct path of the instrument or missile. Source : The NHS UK SPECTRUM OF ABDOMINAL TRAUMA Intraperitoneal - Solid -Hollow -Mesentry Retroperitoneal Abdominal Wall -pancreas - Hematoma (in warfarinized or hemophilia patients after minor trauma) -vascular -kidneys -abdominal aorta MANAGEMENT OF BLUNT TRAUMA MANAGEMENT OF PENETRATING TRAUMA Intraperitoneal •Solid organs • Spleen (40-55%)* • Liver (35-45%)* •Hollow organs • Gastric, bowel, bladder or gallbladder perforation • Penetrating injury •Mesentery (bowel ischaemia) • Bleeding *Emerg Med Clin North Am. 2007 Aug;25(3):713-33, ix Retroperitoneal • Pancreas (10-20%) – traumatic pancreatitis • Vascular(5-10%) – major vessels • Kidneys(5%) • Aorta Splenic injury • Most commonly injured organ in blunt abdominal trauma • May occur after minor trauma in diseased spleen • Splenic injury is graded depending on the extent and depth of splenic haematoma and/or laceration identified on CT scan • Low grade splenic injuries are suitable for non-operative management, although more recent evidence suggests that higher grades may also be suitable with the adjunct of angioembolisation • To be considered if: — a contrast blush is seen on CT — AAST grade > III — moderate hemoperitoneum is present — evidence of ongoing bleeding Splenic injury CONSERVATIVE MANAGEMENT ▫ Hemodynamic stable ▫ Absence of contrast extravasation in CT ▫ Subcapsular Hematoma <50%, Laceration <3cm ▫ Evidence of pseudoaneurysm • Serial abdominal examination and CT scan. • Close monitoring in HDU OPERATIVE MANAGEMENT • Total Splenectomy • Vaccination *Predictive of failure in conservative if : - Active contrast extravasation - Evidence of pseudoaneurysm on CT scan Subcapsular hematoma <10%, Capsular tear <1cm Subcapsular hematoma 10-15% or intraparenchymal <5cm diameter, Capsular tear 1-3cm (not involving vessel) Subcapsular hematoma >50%, ruptured, or parenchymal hematoma. Laceration >3cm involving trabecular vessel Laceration of segmental or hilar vessels producing major devascularization Completely shattered spleen + hilar vascular injury Liver injury •Largest organ - 85% with blunt hepatic trauma are stable •CT with contrast – main stay of diagnosis in stable patient Liver Injury CONSERVATIVE MANAGEMENT • Haemodynamically stable • No other intra abdominal injury require surgery • Close monitoring of patient Failed conservative if - Peritonitis - Hypotension - Evisceration - Proctorrhagia - Hematoma OPERATIVE MANAGEMENT • Liver packing (via tamponade effect) • Pringle’s maneuver – direct compression to portal triad via Foramen of Winslow • Lobar Resection • Liver Transplantation Renal injury • Clinically not suspected & frequently overlooked • Most genitourinary injuries are not immediately life-threatening • Renal pedicle injury can lead to life-threatening hemorrhage and renal ischemia • Clinical - Shock, hematuria & pain over the loin • Urine : gross or microscopic • CT scan – Grading • Indications for nephrectomy • Hemodynamic instability • Grade 5 renal injury / renovascular injury • Extensive contrast extravasation • Expanding / pulsatile retroperitoneal hematoma Vascular injury Zone 1 ; midline retroperitoneum, from aortic hiatus to sacral promontory. The supramesocolic area and inframesocolic area Zone 2 ; kidneys, paracolic gutter and renal vessels Zone 3 ; pelvic retroperitoneum and iliac vessels Hollow Organ injury • Gastric, Gallbladder, Small or Large Bowel, Urinary Bladder, Ureter • Perforations with spillage of content into peritoneal cavity or retroperitoneal space • Sign and symptoms of peritonitis • Treatment : simple suture closure or rapid resection of involved segment, no anastomosis are performed • Complications : • Sepsis • Wound infection • Abscess formation Damage Control Surgery • Patients of blunt or penetrating abdominal trauma with hemodynamic instability are generally better served with abbreviated operations that helps in prevention from the lethal triad of death. Damage Control Surgery Initial operation with hemostasis and packing (OT) Phases of DCS Stabilization of physiological status in ICU Definitive Surgery (OT) Things to monitor Physiological Parameters Haematological Parameters TAKE HOME MESSAGE 1. The correct sequence of priorities for assessment of a multiply injured patient is preparation- triage-primary survey and resuscitation- secondary survey-reevaluationand definitive care. 2. Permissive hypotension is for patients without brain injury. 3. FAST scan has 86-99% in diagnosing intraperitoneal fluid. 4. Special sign’s in recognising abdominal trauma( Cullen sign, kehr sign, grey turner sign, seatbelt syndrome) 5. Indication laparotomy: blunt trauma with hypotension and FAST +ve, penetrating trauma, peritonitis, free air, retroperitoneal air or rupture of hemidiaphragm. 5. Liver and spleen injury most common in blunt trauma 6. Solid organ injury in haemodynamically stable patients can often be managed without surgery 7.Grade I through III hepatic injuries can be managed in a non-monitored setting. Grades IV and V should be admitted to the ICU for close monitoring, serial physical exams and blood counts. 8.Damage control surgery involved controlling hemorrhage allowing subsequent focus on resuscitation, correction of coagulopathy and avoiding hypothermia. References • ATLS for Doctors, 9th edition • Journalarticle.ukm.com.my • Bailey & Love Short Practice of Surgery, 25th edition • http://www.surgeons.org.uk/advanced-trauma-lifesupport/shock.html • Clinical companion in surgery Thank you! PERMISSIVE HYPOTENSION OVERVIEW • Permissive hypotension is also known as hypotensive resuscitation and low volume resuscitation • The concept remains controversial and is primarily applicable to the penetrating trauma patient. • It is considered part of damage control resuscitation, along with haemostatic resuscitation and damage control surgery. APPROACH • Allow SBP to fall low enough to avoid exsanguination but keep high enough to maintain perfusion • Goal is to avoid disruption of an unstable clot by higher pressures and worsening of bleeding (“don’t pop the clot”) • Avoids cyclic over-resuscitation that can lead to rebleeding and paradoxically exacerbate hypotension despite increased fluid resuscitation and subsequent complications • Low BP is not the target, it is a compromise pending emergency surgical intervention • Haemorrhage control is the goal, once this achieved (e.g. haemostasis and surgery) normalisation of haemodynamics is appropriate • A MINIMAL VOLUME NORMOTENSIVE APPROACH • Target = MAP of 65 mmHg (assuming patient is adequately perfused at this blood pressure and there is not a coexistant head injury demanding a higher BP target) — targets above this risk “popping the clot”, fluid overload and dilutional coagulopathy • If MAP < 65 – give fluids/ blood products • If MAP > 65 – check perfusion (strong pulse, warm peripheries) -> MAP > 65 with good perfusion -> perform masterful inactivity -> MAP > 65 with poor perfusion -> give fentanyl 20-25 mcg (decreases catacholamine release resulting in vasodilation, if MAP drops <65 mmHg then give fluids/ blood products as above) DIFFERENCES
