Management of blunt abbominal injury Osama Jalal Kehil Mohammed Habib Mohammed Sbeinatai

Epidemiology Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Identification of serious intra abdominal pathology is often challenging. Many injuries may not manifest during the initial assessment and treatment period.

Causes of trauma MVA Fall from height Gun shot Knife Industrial accidents Natural disasters

Types of trauma Blunt trauma results of an impact from blunt object Penetrating trauma results from an object piercing the body Assessment and diagnosis of blunt injuries are more difficult than of penetrating injuries Multi-trauma- injury affecting simultaneously different organ and body system

Trimodal death in trauma Immediate: Within seconds or minutes after injury 50% of deaths due to injury to the aorta, heart, brainstem, or spinal cord or by acute respiratory distress. Early: Within hours of injury approximately 30% of deaths. Half of these deaths are caused by hemorrhage and the other half by central nervous system (CNS) injury. These patients can be saved by appropriate treatment (golden hour). Late: peaks from days to weeks, mortality due to infection and multiple organ failure.

Pre-hospital care Delivery to the hospital for definitive care as rapidly as possible. Only critical interventions at the scene Airway established, hard collar, spine board, control any external hemorrhage Infusion on way to the hospital

Hospital care ATLS approach A well defined order Primary survey- initial assessment and management Treat the greatest threat to life Immediate intervention as the threat to life is identified Re-evaluation of initial management Secondary survey- head to toe evaluation

A B C D E Primary survey Airway Breathing Circulation Disability (neurologic assessment) Exposure and Environmental control

Primary survey team approach Simultaneous diagnosis and treatment by multiple providers Reduces the time to assess and stabilize a multiple trauma patients Team should be organized before patient arrival.

Airway Verbal response: Salam! How are you? Airway is compromised if: No response- unconscious , airway obstruction Severe facial trauma Oropharyngeal bleeding or foreign body Patient agitated - hypoxia

Airway Adequacy of airway- completed within seconds Open the front of the collar for airway manipulation Maintain manual stabilization by an assistant bag valve mask ventilation Oxygen supplement + pulse oximetry Rapid-sequence endotracheal intubation Frequent reassessment for airway compromise

Difficult airway Surgical airway when oral intubation cannot be accomplished: Cricothyroidotomy Tracheostomy

BREATHING Dyspnoea Unilateral diminished chest expansion Bruising / abrasion Distended neck vein

Circulation Assessment of cardiovascular compromise and management Is the patient in shock? Is there any external bleeding source? Any internal hemorrhage?

Classes of hemorrhagic shock Class I Class II Class III Class IV Blood loss (ml) Up to 750 750- 1500 1500- 2000 > 2000 Pulse <100 >100 >120 >140 BP Normal Decreased

Circulation Indicators of shock in trauma patients Tachycardia Agitation Tachypnea Weak peripheral pulse Hypotension Oliguria

Circulation Initial management External haemorrhage - compression dressing IV access - two peripheral catheters ECG monitoring Blood sample - typing and lab. investigations Initial resuscitation:1-2L of Ringer's lactate or NS Packed RBC if no response Foley’s catheter

Circulation Initial management Search for any source of blood loss: CXR, X-ray pelvis, FAST (focused abdominal sonography in trauma)

Glasgow Coma Scale (GCS) Total = 15 Eye response Vocal response Motor response Spontaneous 4 Oriented 5 Obeys commands 6 To voice 3 Confused 4 Purposeful movement to pain 5 To pain 2 Inappropriate words 3 Withdraw from pain 4 None 1 Incomprehensible words 2 Flexion to pain 3 *** None 1 Extension to pain 2 None 1

Exposure/ Environment control Completely undress the patient Perform a rapid head to toe examination Identify any injuries to the back, perineum, or other areas that are not easily seen in the supine position Unexpected injuries may be discovered Once assessment completed, cover the patient with blanket ( prevent cold exposure)

Secondary Survey Only after completion of primary survey (ABCDE) Life threatening injuries have been controlled Normalization of vital signs A head to toe evaluation Detailed history and examination Continuous reassessment of vital signs Additional lab. & radiological tests

Abdominal injuries 25% of all trauma victims require abdominal exploration. Physical examination is inadequate to identify intra-abdominal injuries Diagnostic modalities - CXR, FAST, CT & laparoscopy Blunt trauma: Hemodynamically stable - CT scan Hemodynamically unstable - FAST

Splenic injury Most frequently injured in blunt trauma. History of injury to the left side of the chest or flank Bruising, pain ,tenderness lower chest and upper abdomen on left side Diagnosis: CT in hemodynamically stable patients FAST in an unstable patients

Splenic injury Non-surgical management Hemodynamically stable patients: CT for diagnosis No other intra-abdominal injury requiring operation Admission to ICU for continuous monitoring Serial Hb. , & repeated abdominal assessment If hypotension develops - taken for surgery

Splenic injury Surgical management Hemodynamically unstable FAST: splenic injury, free fluid (hemoperitoneum) Surgery- splenectomy Polyvalent pneumococcal vaccine (pneumovax)

Liver injury Spontaneous hemostasis Profuse bleeding from deep hepatic lacerations Mortality rate 8% - 10%, morbidity rate from 18% -30%, Diagnosis: FAST in hemodynamically unstable, CT scan in hemodynamically stable Management based on hemodynamic status

Liver injury Non-operative management Hemodynamically stable patients CT scan No other indications for abdominal exploration ICU admission for close observation Serial hemoglobin estimation Surgery- if become unstable

Liver injury Surgical management Principles of surgical management: control of bleeding, removal of devitalized tissue, and adequate drainage. Bleeding vessels & biliary radicles are individually ligated Perihepatic packing- when fail to control hemorrhage Packs removed in 48 hours

Pancreatic injuries Pancreatic injury is rare Caused by penetrating injury or direct blow Diagnosis is difficult to make CT scan, elevated serum amylase may help No duct injury: simple drainage Ductal injury: distal resection

Bowel injuries Mostly due to penetrating trauma Also seen after blunt trauma Features of peritonitis CT scan free air in peritoneum / contrast leak Small bowel: Suture repair Colon: suture repair± proximal colostomy

Renal injuries Minor : renal contusion (85%) Conservative management Major: Deep medullary injuries with extravasation Vascular injuries Surgical repair