1. ABDOMINAL TRAUMA

2. ABDOMINAL VISCUS -Erect position exposes the abdomen -More effective with relaxed muscles -Some organs protected by bony structures) -Some organs project in thorax or pelvis and can be injured in trauma of these regions - Any trauma bellow angle of the scapula (post) or bellow the niple anterior can injure abdominal organs

3. CONCUSSION Causes  Road accidents – 2/3  Work accidents  Agresion  Sport  Varia

4.  ♂ young  Very frequent  Politrauma  Rural accidents

5.  Direct trauma - simple - crush  Indirect trauma - counter hit  B last injury  Mixt mechanism Classification according to type of injury

6. Type of agent  Solid  Explosive waves  Bone fragments Significant factors  Agent  Speed  Force  Direction: perpendicular/tangential  Surface  Natural visceral protection  Associated diseases

7. 1.Parietal lesions  Morel-Lavalle - supraaponeurotic hematoma  Muscle ruptures – hematoma→ properitoneal hematoma - posttraumatic hernia  Associated bone lesions Clasification: pathology

8. Seroma Morell Lavalle Small vessels injury with spontaneous hemostasis – tangential trauma with shearing mechanism Develops in time, but does not feel the entire space available = fluctuence not always present Usually normal skin Will be absorbed in time, sometimes requiring aspiration

9. Hematoma – rectus abdomini rupture Anatomic particularities: –Fascial intersections that segment the muscle –Rectus sheet –Abundant network of vessels, large vessels inside the sheet Hematoma is well circumscribed, in tension, developed between two intersections. During contraction of the wall: painful and does not disappear inside the abdomen. Diagnostic: sudden onset, related to trauma are fundamentals in understanding the diagnosis.

10. Hematoma – psoas muscle rupture Anatomic particularities: –Situated deep in retroperitneum –Adjacent to branches from the lumber plexus) Developed in the retroperitoneum Disappears during abdominal wall contractions Diagnostic: sudden onset, related to trauma are fundamentals in understanding the diagnosis May appear spontaneous

11. Rupture of the diaphragm Indirect mechanism via an acute increase in abdominal pressure Direct mechanism – crushing the base of the thorax False herniation of abdominal viscus in the thorax. (false = no peritoneum) Respiratory problems due to intrathoracic compression Digestive problems – difficult to evaluate in a trauma patient with more serious lesions.

12. Traumatic diaphragmatic hernia

13. Posttraumatic hernia Early or late complication of trauma BREAK IN THE MUSCULAR-FASCIAL LAYER – may be obscured by gravity of initial trauma In time it develops like a true hernia through a new week point Symptoms are very similar to all postoperative hernia BUT no scar

14. 2. Intraabdominal organ lesions A.Cavitary – 1/3 Small bowell ruptures – most frequent - ruptures - complet - incomplet - secondary perforations - posttraumatic stenosis Stomach – more often on a full stomach

15. Duodenum – DII, DIII - Retroperitoneal spillage: bile, blood and gas Colon – - peritoneum - retroperitoneum VERY SERIOS: FECAL PERITONITIS

16. Bile ducts - gallbladder - CBD COLEPERITONEUM Bladder – 3% (intra or extraperitoneal)

17. B. Parenchimatous organs Fissure, ruptures, avulsion of pedicle Hematoma: - subcapsular - central  Liver – 25%  Spline – 50%  Pancreas – 5%  Kidney – 10% → ! Hemorhage in 2 seq

18. Abdominal wounds

19. Classification Superficial Penetrate –Perforated 20% of all peace time abdominal trauma 90% of all war time abdominal trauma Wounds and contusions can be present in the same time

20. Non-penetrated abdominal wounds Diagnostic is essential = lack of penetration Intact serosal layer – difficult to appreciate especially in a blunt trauma with a wound

21. DIAGNOSTIC CRITERIA Anamnesis –Weapon and trajectory –Relative position of aggressor and victim –Direction of the weapon as it hits –Physiologic status –Number of wounds

22. Local examination Gentle, after a careful antiseptic preparation of the skin and wound Use a blunt gentle instrument to probe the wound If not a simple stab wound (that is complex wounds with non-linear trajectory) the information will always be incomplete. ATTENTION to strata movements between impact and examination An examination with a negative result is not necessary conclusive

23. General examination of the abdomen Look for signs and symptoms suggestive for penetrating and perforated wound Monitor the clinical status of the patient – that is safe in the case of a negative evaluation (regarding a probable superficial wound) –Admit patient for hospital care for at least 24 hours

24. Lab exams Their purpose is to identify signs of major syndromes related to the peritoneal cavity –Peritonitis –Hemorrhage –Intestinal obstruction –Acute pancreatitis According to type of wound and trajectory

25. Surgical evaluation of the abdominal cavity In this case IT IS a method of EXPLORATION –Laparotomy –Laparoscopy MAJOR LIMITS Check the integrity of the peritoneal surface Check the integrity of viscus Check for fluid in periteneum TYPE HOW MUCH IS COMPLETEAndominal exploration should be as complete as possible – HOW MUCH IS COMPLETE

26. TAKE GOOD CARE Any abdominal wound (even very small or apparently without significance) can be penetrated. MINIMAL ACCESS SURGERY A small wound can be accompanied by a big disaster in the abdomen. Initial evaluation can be misleading

27. Penetrated wounds All the abdominal wall has been penetrated (including the parietal peritoneum) but no viscus in injured It is not common – more frequent with stab wounds Exploration – same methods

28. Clinical evaluation Wound exploration: –How much the instuments can be inserted in comparison with the width of the abdominal wall = RELATIVE –Is the probe free to move? = RELATIVE If the wound is large enough abdomina viscus can herniate outside = DIAGNOSTIC

29. Significance Major risk for a viscus injury, even if not apparent Major risk to err due to absence of clinical manifestation at presentation Risk of infection of the peritoneal cavity In traumatic evisceration – risk of strangulation

30. Perforated wounds Symptoms depend on viscus involved and time interval from lesion (25-35% multiple organs affected) Dg obvious when in the wound –Digestive content OR colonic content OR blood in quantity larger then we expect ????? –Symptoms develop in time – check for patients condition

31. MAJOR LESIONS: cavitary organs 1. Stomach Concussions: simple hematoma – to dilaceretion Gastric wounds: anterior or posterior wounds

32. 2. Duodenum - simple concussions - intramural hematoma : may develop instestinal obstruction, perforation, or nothing - rupture: complete or incomplete; total or partial –intraperitoneal (cu peritonită) –retroperitoneal - duodenal wounds MAJOR LESIONS: cavitary organs

33. 3. Small bowel and mesentery – most frequent - Hematoma of the intestinal wall: may develop obstrution, perforation or resolution. PERFORATION IS IN 2 SEQUENCES - ruptures -wounds – a wide range of complexity -Hematoma and ruptures of mesentery: may affect the bowell and may produce massive bleeding MAJOR LESIONS: cavitary organs

34. 4. Colonul and mesocolon: same as small bowell but content more septic 5. Rectum - penetrating wounds: trauma of the pelvis, gunshot, falling in sharp objects - iatrogenic trauma - unusual causes ingested foreign body foreign bodies introduced in the rectum - explosions following hyperinflation (strange jokes, psyhopatic behavior). MAJOR LESIONS: cavitary organs

35. 1. Liver a) Primary lesions of the parenchim: - Subcapsular hematoma – preservation of the capsule which can retain large volumes: major risk for secondary rupture (hours – days) secondary hemoperitoneum - Wounds and ruptures ; -Avulsion b) Lesions of the hepatic pedicle: gallbladder, CBD, major vessels MAJOR LESIONS: solid organs

36. 2. Spline -ruptures and wounds; -Subcapsular hematom – secondary rupture in peritoneal cavity -Avulsion of the pedicle 3. Pancreas – unusual 1-2% - crash usually - simple concussion -rupture with small duct lesions; - rupture with Wirsung duct lesion; - crushing Major problem: pancreatitits MAJOR LESIONS: solid organs

37. D. Retroperitoneal hematoma May associate: -Pelvic fractures or vertebral fractures; -Injury of the bug vesseks in the retroperitoneu -Trauma of the adrenal glands -Trauma of the kidney. E. Kidney trauma a) Renal parenchime - hematoma with intact capsule; - fissure with broken capsule; - dileceration of renal parenchime b) Renal pedicul: elements of the pedicul including the urinary system, MAJOR LESIONS: solid organs

38. III. DIAGNOSTIC Evalution of vital function Conscience Full examination Hierarchy of lesions Repeated examination: dynamic of lesions

39. III. DIAGNOSTIC 1.ANAMNESIS

40. 2. Clinical examination Signs of hemodynamic instability Abdominal wall lesions Major abdominal syndromes PLUS: - large bore venous access - naso-gastric aspiration - urinary catheter

41. CLINICAL EXAMINATION * inspection * palpation * percussion * auscultation * Rectal/Vaginal examination

42. 3. Evaluation a) hematoogcal b) chemistry c) radiology - plain abdominal X-Ray - thoracic X-Ray: must be done in abdominal wounds - water soluble digestive studies - intravenous urography - cystografy: lesions of the bladder - diagnsotic peritoneal lavage: careful to contraindications (obstructions, adhesions)

43. 3. Evaluation a) US b) CT scan (spiral) c) Laparoscopy

44. TREATMENT Catastrophe management Individual care for each involved organ –Hemostasis –Resections –Suturing –etc