ABDOMINAL TRAUMA ABDOMINAL VISCUS Erect position exposes the

ABDOMINAL TRAUMA

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

CONCUSSION • Causes Ø Road accidents – 2/3 Ø Work accidents Ø Agresion Ø Sport Ø Varia

Ø ♂ young Ø Very frequent Ø Politrauma Ø Rural accidents

Classification according to type of injury ØDirect trauma - simple - crush ØIndirect trauma - counter hit Ø Blast injury Ø Mixt mechanism

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

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

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

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.

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

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.

Traumatic diaphragmatic hernia

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

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

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

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

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

Abdominal wounds

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

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

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

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

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

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

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 • Andominal exploration should be as complete as possible – HOW MUCH IS COMPLETE

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

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

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

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

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

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

MAJOR LESIONS: cavitary organs 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 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 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: solid organs 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 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 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,

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

III. DIAGNOSTIC 1. ANAMNESIS

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

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

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)

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

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