1. © ACS 1 Budi Irwan Bagian Bedah FK USU – RSUP H.Adam Malik - Medan

2. © ACS 2 Objectives  Describes the significance of the anatomic regions of the abdomen  Recognize the difference between blunt and penetrating injury patterns

3. © ACS 3 Anatomy External  Anterior abdomen  Flank  Back

4. © ACS 4 ANTERIOR ABDOMEN As the area between the transnipple line superiorly Inguinal ligaments and Symphysis pubis inferiorly And the anterior axillary lines laterally

5. © ACS 5 FLANK This is the area between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest

6. © ACS 6 BACK This is the area located posterior to the posterior axillary lines from the tip of scapulae to the iliac crests.

7. © ACS 7 Anatomy

8. © ACS 8 Peritoneal cavity Upper Peritoneal cavity : Covered by the lower aspect of the bony thorax, and includes the diaphragm, liver, spleen, stomach, and transverse colon

9. © ACS 9 Pelvic Cavity : Which is surrounded by the pelvic bones It contains the rectum, bladder, iliac vessel, and in women, internal reproductive organs.

10. © ACS 10 Retroperitoneal space This potential space is the area posterior the peritoneal lining of the abdomen, and contains the abdominal aorta, inferior vena cava, most of the duodenum, the pancreas, kidneys and ureters and the posterior aspects of the ascending colon and descending colon.

11. © ACS 11 Blunt Trauma A direct blow, eg, contact with the lower rim of the steering wheel May cause a compression or crushing injury to the abdominal viscera These forces deform solid or hollow organs and may cause rupture Shearing injury to the abdominal viscera are a form of crushing that may result when a restraint device is worn improperly  Deceleration (fixed organs)

12. © ACS 12 Blunt Trauma The organ most frequently injured include : Spleen (40% - 50%) Liver (35% - 45%) Small bowel (5%-10%) 15% incidence of retroperitoneal hematoma

13. © ACS 13 Penetrating Trauma Stab wounds and low velocity gunshot wounds cause tissue damage by laceration or cutting High velocity gunshot wounds transfer more kinetic energy to abdominal viscera

14. © ACS 14 Penetrating Trauma Stab wounds Most commonly involved : Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%)

15. © ACS 15 Penetrating Trauma Gunshot wounds Most commonly involved : Small bowel (50%) Colon (40%) Liver (30%) Abdominal vascular structures (25%)

16. © ACS 16 Initial Assesment Objective : Apply the diagnostics and therapeutic procedures specific to abdominal trauma

17. © ACS 17 Initial Assessment History Blunt ♦ Speed of the vehicle ♦ Type of collision (Point of impact) ♦ Vehicle intrusion to the passenger compartement ♦ Safety devices ♦ The patient’s position in the vehicle ♦ Ejection Penetrating ♦ Type of Weapon ♦ Distance from the assailant

18. © ACS 18 Assessment : Physical Exam  Inspection  Auscultation  Pecussion  Palpation

19. © ACS 19 Inspection The patient must be fully undressed Inspected for : - Abrasions - Contussion - Lacerations - Penetrating wounds - Foreign bodies - Evisceration of omentum and small bowel - Pregnant state

20. © ACS 20 Auscultation To confirm of bowel sounds Injuries to adjacent structures (rib,spine, or pelvis) may produce an ileus Absence of bowel sounds is not diagnostic of intra abdominal injuries

21. © ACS 21 Percussion May demonstrate: - the tympanitic sounds over an acute gastric dilatation in the left upper quadrant - diffuse dullness when a hemoperitoneum is present.

22. © ACS 22 Palpation - The goal of palpation is to elicit and localize superficial, deep, or rebound tenderness. - The presence of a pregnant uterus, as well as estimation of fetal age, also can be determined

23. © ACS 23 Evaluation of penetrating wounds  Local wound exploration by surgeon  Assessing Pelvic Stability : Manual compression of the anterosuperior iliac spines or iliac crest may elicit abnormal movement or bony pain (suggest a pelvic fracture)

24. © ACS 24 Evaluation of penetrating wounds ♦ Penile, perineal: The presence of blood at the urethral meatus, ecchymoses or a hematoma at scrotum and perineum strongly suggest a urethral tear. ♦Rectal Examination : To assess sphincter tone, Position of the prostate and to determine wether fractures of the pelvic bones.

25. © ACS 25 Evaluation of penetrating wounds ♦Vaginal examination : Laceration of the vagina may occur from bony fragments from pelvic fracture(s) or from penetrating wounds. ♦Gluteal examination : Penetrating injuries to this area are associated with up to 50% incidence of significant intraabdominal injuries.

26. © ACS 26 Pelvic fracture

27. © ACS 27 Insertion Gastric Tube 1. Relieves dilatation 2. Decompresses stomach before DPL Caution : Basilar skull / facial fractures May induce vomiting / aspiration

28. © ACS 28 Insertion Urinary Catheter  Monitors urinary output  Decompresses bladder before DPL  Diagnostic Caution : Urethral injury

29. © ACS 29 Blood and Urin Sampling ♦Blood : - Complete blood count (CBC) - Potassium - Glucose - Amylase (for blunt trauma) - Blood alcohol levels

30. © ACS 30 Blood and Urin Sampling ♦Urin : Urine specimens are sent for a urinalysis and urine drug screen if indicated. “A blood test or urine pregnancy test is indicated in all females of childbearing age”

31. © ACS 31 Diagnostic Peritoneal Lavage (DPL) A DPL is a rapidly performed, invasive procedure that significantly alters subsequent examinations of the patient and is considered 98 % sensitive for intraperitoneal bleeding.