Topic review penetrating_abdominal

น ำเสนอวันพุธที่ 28 มีนำคม 2555

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Topic Review :Penetrating abdominal Trauma

Learning Topic

Anatomy of abdomen

Mechanism of Injury

Management

Anatomy of Abdomen

Anat

omy

of A

bdom

en

InternalThoracic

cavity

Peritoneal

cavity

Retro -

peritoneal

space

Pelvic

cavity

ExternalAnterior

abdomenFlank Back

Thoraco -

abdominal

Anatomy of Abdomen (External)

Anatomy of Abdomen (Internal)

Mechanism of Injury

• Compression

• Crushing

• Shearing

• Deceleration

(fixed organs)

Blunt

• Laceration / low

energy

• Kinetic energy /

high energy

Penetrating

Mechanism of Injury

Mechanism of Injury

• Minimal symptom : high negative explore.

• Complication from surgery : 22 %

• Selective management.

Stab wound

• Higher Risk for internal organ injury

• Risk of visceral organ injury : 90%

• Suggest to operate.

Gunshot wound

Mechanism of Injury

• Many small bullets

• Severity depend on distance of victim from weapon.

• Type I : Long range. ( > 7 yards )

• Subcutaneous. No need for operation

• Type II : Short range. ( 3-7 yards )

• Need operation & suture. Mortality 20 %

• Type III : Very short range. (< 3 yards )

• Large defect , Need operation, Mortality rate 85-90 %

Shotgun wound

Management

Surgery without Investigation

Penetrating injury

Gun shot wound

(not tangential)

Penetrating wound

with

Peritonitis

Hypotension

Evisceration

Penetrating abdominal trauma

Anterior abdomen Flank or back

Stab woundGunshot wound

Local explore wound

Observe

CT ScanTangential wound ?

ObserveDPL or

Dx Laparo DPL or

OR

Circulatory status

Surgical abdomen

Stable

Unstable OR

OR

OROR

No

No

Yes

Yes+ve+ve-ve -ve

Penetrating Thoracoabdominal TraumaAcute phase

ResuscitateATLS protocols

Insert NG if nocontraindications

CXRNormal Abnormal

Indications for

surgical intervention present

(ie: Thoracotomy orLaparotomy)

Indications for

surgical intervention present

(ie: Thoracotomy orLaparotomy)

No indication for

surgical intervention

No indication for

surgical intervention

OR

Examine diaphragm

Right side Left side

Admit

ObserveRepeat CXR

Laparoscopy

or thoracoscopy

Laparoscopy

or thoracoscopy

OR

Examine diaphragm

Consider CTObserve

Right side Left side

Investigation

Diagnostic peritoneal lavage

Diagnostic Laparoscope

Local Wound Exploration


- performed after gastric and urinary bladder decompression

- Aspirate the content from intraabdomen.

If aspiration is negative : lavage.

Put in isotonic solution

Lactated Ringer’s solution or normal saline

A liter in adult and 20 ml/kg in children

Mixing of the lavage fluid.


Criteria for Diagnostic from DPL

At least 10 ml of gross blood

RBC count at least 100,000 / mm3

WBC count at least 500 / mm3

Amylase > 19 IU/L

ALP > 2 IU/L

Bilirubin level > 0.01 mg/dL

Food particle , fecal material , bile , bacteria

Fluid come from NG , urinary catheter , ICD


False positive :

• Bleeding from the lavage site

• Injury of the omentum or mesentery by lavage catheter

False negative :

• Faulty catheter placement

• Compartmentalization of the abdomen by adhesion

• Bleeding is slow and perform DPL too early

• Rupture diaphragm

Diagnostic Laparoscope

Useful in :

Thoracoabdominal wounds.

Tangential GSW

Equivocal stabbed wound

Advantage : Direct examination of intraperitoneal structure

Local Wound Exploration

Evaluation the depth of the wound.

Determine whether they penetrate the peritoneum.

Usually performed in the wound that located

anterior to the anterior axillary line.

? Question

Reference

• Schwartz's Principles of Surgery, 9th Edition, 2010

• Sabiston Textbook of Surgery, 17th Edition, 2004

• Tintinalli's Emergency Medicine, 7th Edition, 2011

• Rosen’s Emergency Medicine 7th Edition, 2010

• ATLS Advanced Trauma Life Support for Doctors 8th

Edition, 2008

• Evaluation of Abdominal Trauma, American Collage of Surgeons, 2003

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Education

Topic review penetrating_abdominal