Management of Blunt and Penetrating Abdominal Trauma in

Management of Blunt and Penetrating Abdominal Trauma in Children Department of pediatric surgery Kharkov State Medical University

Motivation • Trauma is the leading cause of death in the pediatric population, and injuries to the abdomen are third leading cause of pediatric trauma death, after injuries to the head and thorax. • The abdomen is the most common site of unrecognized fatal injury in pediatric trauma.

Errors are still present: • Children often cannot adequately communicate their injuries to physicians • They are better able to compensate for significant injuries, which makes vital signs less helpful in identifying injuries early. Children can lose up to 45% of their total blood volume before showing any changes in blood pressure

Mechanisms for Intra abdominal Trauma 1. 2. 3. 4. 5. 6. Motor vehicle collisions, pedestrian strucks (50 %) Falls (up to 45 % in developed countries) Bumps, assaults Handlebar injury from bicycle Sports injuries Non accidental trauma (child abuse 5%)

The Waddell triad of injuries to head, torso, and lower extremity

The mechanism for the development of intestinal and vertebral injuries from lap belts

Children are predisposed because: • They are not small adults. • have much more pliable skeletal systems, which helps reduce their risk of fracture but in turn results in decreased protection of internal organs. • The bladder has not yet settled into the pelvis. • Children have less fat and muscle to protect them. Along with the loose attachments of the intestines, these put them at higher risk for deceleration injuries. • Children have a much smaller surface area over which to distribute the force of impact.

1. In the hemodynamically unstable patient with a distended abdomen, immediate operative intervention is indicated after completion of the primary and secondary surveys. 2. In less critically ill patients, further diagnostic evaluation for an intra abdominal injury is indicated.

• Primary survey: Quick, initial patient assessment to identify life threatening injuries Occurs with active resuscitation • Secondary survey: More detailed assessment of injuries

Primary Survey • A, B, C, D, E • Every trauma patient should arrive boarded and C spine immobilized Collar for school age/adolescents Rolls and tape for infants/toddlers • Immediate vitals signs

A, B, C, D, Es A = Airway & C Spine precausions B = Breathing (H/PTX) C = Circulation D = Disability E = Exposure F = Foley catheter unless contraindicated G = Gastric tube unless contraindicated

A: Airway & C Spine Protection Check for airway patency and clear secretions, blood, foreign bodies, loose teeth Open: jaw thrust/spinal stabilization Clear: suction/remove particulate matter Support: oropharyngeal/nasopharyngeal airway Establish: orotracheal/nasotracheal intubation* Maintain: primary/secondary confirmation Bypass: needle/surgical cricothyroidotomy Ensure adequate C spine protection

Indications for intubation An airway unsecured because of coma, combativeness, shock, or direct airway burns / trauma requires endotracheal intubation. 1. Airway or breathing compromise (present or predicted) 2. Unprotected airway 3. GCS < 9 4. Combative 5. Uncooperative patients requiring CT, aortography etc.

B: Breathing Check for adequacy of breathing Effort, breath sounds, oxygenation Apply oxygen by facemask or blowby Consider need for intubation If already intubated confirm ETT position with: Chest x ray if available End tidal CO 2 or pedi cap if available Oxygen saturation if available Auscultate the lungs for equal air entry Take a look with a laryngoscope

Breathing/Chest Wall • Ventilation: chest rise/air entry/effort/rate • Oxygenation: central color/pulse oximetry • Support: respiratory distress—NRB mask/respiratory failure — BVM ventilation • Chest wall: ensure integrity/expand lungs • Tension pneumothorax: needle decompression, chest tube* • Open pneumothorax: occlusive dressing, chest tube • Massive hemothorax: volume resuscitation, chest tube Do not wait for confirmatory chest radiograph! NRB, non rebreather mask; BVM, bag valve mask.

C: Circulation Most common cause of shock in pediatrics = hypovolemia TBV of child = 80 ml/kg 2 large bore IV’s started Xmatch or Type and screen ordered 20 ml/kg IV crystalloid bolus (x 3 then PRBC’s) Look for obvious and non obvious sources of bleeding

Circulation/External Bleeding • Stop bleeding: direct pressure, avoid clamps; consider arterial tourniquets, topical hemostats • Shock evaluation: pulse, skin CRT, LOC • Blood pressure: avoid over/undercorrection Infant/child: low normal, 70 + (age x 2) mm Hg Adolescent: low normal, 90 mm Hg • Volume resuscitation: Ringer’s lactate (RL), then packed cells Infant/child: 20 m. L/kg RL, repeat x 1 -2 with 10 m. L/PRBCs Adolescent: 1 -2 L, repeat x 1 -2 with 1 -2 units PRBCs

D: Disability • Pupils reactive? Equal? • GCS (modified) or Verbal Score • Spontaneously moving? • Obvious deformities?

Pediatric Verbal Score Verbal Response V-Score Appropriate words/coos Smiles, fixes/follows Cries but consoles 5 Persistently irritable 3 Restless, agitated 2 None 1 4 From American College of Surgeons’ Committee on Trauma. Advanced Trauma Life Support for Doctors (ATLS) Student Manual. 7 th ed. Chicago: American College of Surgeons; 2004.

Glasgow Coma Scale (GCS) Eye Opening q. Spontaneous 4 q. To voice 3 q. To pain 2 q. None 1 Verbal Response (Peds) q. Appropriate 5 q. Cries, consoles 4 q. Persistently irritable 3 q. Restless, agitated 2 q. None 1 Motor Response q. Obeys Commands 6 q. Localizes pain 5 q. Withdraws to pain 4 q. Flexion with pain 3 q. Extension to pain 2 q. None 1

E: Exposure Assess all surface areas (SBS!) Log roll with using spinal precautions Examine the spine: note step deformities or pain Assess rectal tone and sensation Check for vaginal/urethral bleeding Prevent hypothermia Keep trauma room warm, use blankets and overhead warmer for infants

IDENTIFY INTERVENE Airway Primary Survey Goals Inadequate airway Secure and protect Breathing Apnea Positive pressure ventilation Hypoxia Supplemental oxygen Tension pneumothorax Needle decompression, chest tube Massive hemothorax Chest tube Open pneumothorax Occlusive dressing, chest tube Circulation Hypovolemic shock Fluid bolus, blood products Pericardial tamponade Fluid bolus, pericardiocentesis, thoracotomy Cardiac Arrest Chest compressions, thoracotomy if penetrating trauma Disability Spinal cord injury Immobilization Cerebral herniation Hyperventilation, mannitol Exposure

Secondary Survey • • Head to toe examination Tetanus status IV antibiotics if necessary AMPLE history: allergies, medications, past medical history, last meal, events surrounding injury

Vascular Access The IO Needle • If unable to secure access in 90 seconds = IO • Provides immediate vascular access when needed • Safe to administer fluids, drugs, blood products • Can be left for up to 72 h • Use until more secure vascular access

IO: Procedure • • 14 to 20 gauge IO needle with stylus Prepare area in sterile fashion and use local anesthetic Landmarks: proximal medial aspect of tibial plateau, 1 plateau 2 cm distal to tuberosity (aiming away from growth plate); distal femur, 1 2 cm proximal to superior border distal femur of patella Insert needle at 900 angle to bony surface Avoid putting hand behind limb where IO inserted Slowly twist after puncturing the skin until ‘release’ felt Connect to IV tubing Secure to skin with tape and gauze

IO Insertion http: //emedicine. medscape. com/article/940993 -overview

Tools Available For Abdominal Trauma Physical exam X Rays Ultrasound (FAST) DPL Computerized Tomography (CT) Magnetic Resonance Imaging (MRI) Diagnostic Laparoscopy Exploratory laparotomy

The Abdomen is More Than Just the Abdomen • Abdomen: Intraperitoneal cavity • Clinical exam • FAST • DPL • CT scan • Exploratory laparoscopy • Exploratory laparotomy Retroperitoneal cavity & pelvis • Pelvic xray • CT scan • Exploratory laparotomy • Thorax (thoracoabdominal injuries) CXR • Heart & Great Vessels (cardiac box injuries) Cardiac FAST CXR • Diaphragm & Bladder (innocent bystanders) Diagnostic laparoscopy CT cystogram

What Are We Worried About? • Bleeding: Spleen Liver Kidneys Mesentery • Bowel: Contamination (rupture), haematoma, mesentery • Bladder: Intraperitoneal rupture • Diaphragm: Mainly on the left side

Frequency of Pediatric Blunt Abdominal Injuries • Spleen 37% • Kidney 27% • Liver 18% • Pancreas 2% Abdominal bruisisng

Physical Examination • Neither sensitive nor specific to rule out intra peritoneal hemorrhage (Kulenkampff’s, Weinert’s, Rozanov’s “tilting doll” sign) • Excellent to watch for the development of peritonitis (contamination) • Very poor to detect bladder or diaphragmatic injury

Physical Examination • Generally unreliable due to distracting injury, spinal cord injury • Look for signs of intraperitoneal injury abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension entrance and exit wounds to determine path of injury. Distention pneumoperitoneum, gastric dilation, or ileus Ecchymosis of flanks (Gray Turner sign) or umbilicus Gray Turner sign (Cullen's sign) retroperitoneal hemorrhage Cullen's sign Abdominal contusions – eg lap belts and bruises ↓bowel sounds suggests intraperitoneal injuries Rosen’s Emergency Medicine, 7 th ed. 2009

X RAY Patients with suspected intra abdominal injuries should undergo radiographic evaluation of the lateral cervical spine, chest, and pelvis. Although these studies are unlikely to verify an intra-abdominal injury, they may reveal important other injuries. The chest radiograph may demonstrate massive gastric distention and the position of the nasogastric tube. Rarely free intraperitoneal air, foreign bodies and missiles can be elicited.

Initial chest radiograph of an injured child demonstrating massive gaseous distention of the stomach.

Other imaging Angiography To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable patient Rarely used for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma

FAST The FAST (focused assessment with sonography in trauma) exam is an option in the initial evaluation of trauma patients, when a quick decision must be made (either to initiate immediate celiotomy or to continue resuscitation and evaluation for extra-abdominal hemorrhage or severe brain or spinal injury. ). This quick bedside study evaluating for the presence of free fluid in: • perihepatic & hepato-renal recess [Morison pouch], • splenorenal space, • pelvis (Pouch of Douglas/rectovesical pouch), • pericardial space (subxiphoid)

FAST

FAST Morrison’s pouch (hepato renal space) Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow).

FAST Retrovesicle (Pouch of Douglas) Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid.

FAST • Advantages: Portable, fast (<5 min), No radiation or contrast Less expensive • Disadvantages Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. Limited by obesity, substantial bowel gas, and subcut air. Can’t distinguish blood from ascites. high (31%) false negative rate in detecting hemoperitoneum in the presence of pelvic fracture

Diagnostic Peritoneal Lavage (DPL) • • Described in 1965, standard of care Open, semi open or closed (Seldinger) approach Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%) Lead to a non therapeutic laparotomy rate of 36% Laparotomy when: 10 cc gross blood Enteric contents 1 L warmed NS: > 100 000 RBC / mm 3 or > 500 WBC / mm 3 High false positives with pelvic fractures Do a supraumbilical approach High Sn for hollow viscus injuries Moreso than CT Risk of visceral injury = 0. 6% Retroperitoneum can’t be assessed

Diagnostic Peritoneal Lavage In real life: 1. Good tool if FAST equivocal in the HD abnormal pt. in the setting of a pelvic fracture 2. FAST unavailable, pt. is HD abnormal

Diagnostic Peritoneal Lavage • Largely replaced by FAST and CT • In blunt trauma, used to triage pts who is HD unstable and has multiple injuries with an equivocal FAST examination • In stab wounds, for immediate determination of hemoperitoneum, intraperitoneal organ injury, and detection of isolated diaphragm injury • In GSW, not used much

Computerized Tomography • Imaging modality of choice only in HD normal patients Pts crumping in CT a performance indicator in trauma centres • Sn = 92 97%, Sp = 99% for bleeding Active arterial contrast extravasation, blush or pseudoaneyrysm • Only modality to directly detect retroperitoneal injury • Poor test to diagnose diaphragmatic injury • Less accurate for HVI Still need serial physical exams If pelvic fluid is present in absence of solid organ injury – exploratory laparotomy is mandated, especially if moderate or large amounts of free fluid

Computerized Tomography 1. CT is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple extra abdominal injuries. neurologic injury multiple Under these circumstances, patients with a negative CT should be admitted for observation 2. CT is the diagnostic modality of choice for non operative management of solid visceral injuries (i. e. bleeding). If HD stable with a positive FAST, follow up CT permits nonoperative management of select injuries 3. In HD stable patients, DPL and CT are complementary diagnostic modalities

Computerized Tomography By minimizing the incidence of non therapeutic laparotomies for self limited injury to the liver or spleen, trauma centers are using CT with intravenous (IV) contrast only.

Non operative management of solid organ injury is now more common ATLS advanced trauma life support PALS pediatric advanced life support

Initial Management of the Bleeding Patient – European Guidelines; 2007 • Recommendation 1: That time elapsed between injury and operation be minimized for pts. In need of urgent surgical control • Recommendation 2: That a grading system be used to assess the clinical extent of hemorrhage • Recommendation 3: pts. presenting in hemorrhagic shock AND an identified source of bleeding undergo an immediate bleeding control procedure UNLESS initial resuscitation measures are successful • Recommendation 4: pts. with an unidentified source of bleeding in hemorrhagic shock should undergo immediate further assessment • Recommendation 5: Trauma pts. should be resuscitated initially with crystalloid to a BP of 80 100 mm. Hg in the absence of TBI

Initial Management of the Bleeding Patient – European Guidelines; 2007 • Recommendation 6: Early FAST for the detection of FF in patients with suspected torso trauma • Recommendation 7: Pts. with significant FF on FAST with hemodynamic instability should undergo urgent surgery • Recommendation 8: HD normal pts. with suspected head, chest and/or abdominal bleeding following high energy injuries should undergo further assessment using CT • Recommendation 9: Single Hct is not helpful; lactate or base deficit is helpful to estimate and monitor the extent of bleeding and shock

Fluid Administration in Pediatric Abdominal Trauma

Initial Resuscitation • Identify what is bleeding: “ 4 Identify & on the floor” 1. Chest 1. CXR 2. 3. Intraperitoneal abdomen • Very little to do in the trauma bay prior to OR if HD abnormal: Intubate 1. FAST CXR Retroperitoneal abdomen Group & screen 1. PXR, CT scan 4. Extremities – (femur #s) 1. XRs • Then stop it: OR Angioembolization Tourniquet • If crashing: Bilateral chest tubes • If dying: ED thoracotomy Reduction & stabilization • Get to OR ASAP

Patient in Extremis = ED Thoracotomy

Indications for Laparotomy – Blunt Abdominal Trauma Absolute Indications: 1. Shock (HD unstable patients with a positive FAST) 2. Frank Peritonitis (HVI) 3. Blood out of NG tube or on rectal exam 4. Intraperitoneal bladder rupture 5. Diaphragmatic rupture 6. Positive DPL

Indications for Early Operation in Abdominal Trauma in Childhood Blunt Hemodynamic instability despite adequate volume resuscitation Transfusion requirement >50% of estimated blood volume Physical signs of peritonitis Endoscopic evidence of rectal tear Radiologic evidence of intraperitoneal or retroperitoneal gas Radiologic evidence of gastrointestinal perforation Radiologic evidence of renovascular pedicle injury Radiologic evidence of pancreatic transection Bile, bacteria, stool, or >500 WBC/mm 3 on peritoneal lavage Penetrating All gunshot wounds All stab wounds associated with evisceration; blood in stomach, urine, or rectum; physical signs of shock or peritonitis; radiologic evidence of intraperitoneal or retroperitoneal gas All suspected thoracoabdominal injuries (unless excluded by thoracoscopy or laparoscopy) Bile, bacteria, stool, or >500 WBC/mm 3 on peritoneal lavage

ATTENTION! • In stable – go to the OR for a laparotomy In stable If you are worried about contamination (HVI) • Fluid in the pelvis in absence of SOI If you are worried about an intraperitoneal bladder injury or large diaphragmatic injury • In unstable – go to the OR for a laparotomy In unstable If the bleeding is in the abdominal cavity If the bleeding is in the pelvis for packing as still ongoing after stabilizing

Open Book Pelvic Fracture

Pelvic Fracture has large potential space for hemorrhage

Initial Management of the Bleeding Patient – European Guidelines; 2007 • Recommendation 10: Pts. in shock with pelvic ring fractures should undergo immediate closure and stabilization • Recommendation 11: If ongoing instability, proceed to early angioembolization or surgical bleeding control such as packing • Recommendation 12: Early bleeding control must be achieved by packing, direct surgical bleeding control, the use of local hemostatic procedures. If pt. is exsanguinating, aortic cross clamping may be employed as an adjunct • Recommendation 13: Damage control surgery should be employed in the severely injured pt. with signs of shock, ongoing bleeding and coagulopathy

Management of Pelvic Trauma Surgical consult Pelvic wrap Intraperitoneal gross blood? Yes No Laparotomy Angiography Control hemorrhage Fixation device

Col (ret) Mark W. Bowyer MD Close Pelvis – Many Devices Available to Close Pelvic Ring

The Lethal Triad of Death

Damage Control Resuscitation • Damage Control Conception patients with major exsanguinating injuries may not survive complex procedures • Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair

Damage Control Resuscitation • Permissive hypotension • 1: 1: 1 resuscitation (p. RBCs, platelets, FFP) • Damage control surgery Stop the bleeding (pack) Control the contamination Definitive surgical anatomical restoration later

Damage Control Resuscitation 0. Initial resuscitation 1. Control of hemorrhage and contamination Control injured vasculature, bleeding solid organs Abdominal packing 2. Back to the ICU for resuscitation Correction of hypothermia, acidosis, coagulopathy 3. Definitive repair of injuries 4. Definitive closure of the abdomen

Specific visceral injuries

Splenic Trauma • Diagnosis: • Plain abdominal film • Unreliable and nonspecific • Triad of radiographic findings in acute splenic rupture • Left diaphragmatic elevation • Left lower lobe atelectasis • Left pleural effusion Radiograph demonstrates a left pleural effusion, left basilar atelectasis, and inferomedial displacement of the splenic flexure (arrow)

Splenic Trauma • Diagnosis: • FAST • Focused Assessment with Sonography in Trauma • Bedside study for unstable patient • 15% false negative • May miss up to 25% of liver and spleen injuries • Compared to CT only 63% sensitive for detecting free fluid Fluid in the subphrenic space and splenorenal recess can be detected. The image shown demonstrates blood (arrow) between the spleen (S) and diaphragm (D).

Focused Assessment With Sonography in Trauma (FAST) • Looks for free intra abdominal fluid (assumed to be blood or gastrointestinal content, may be other) Also pericardial fluid • Non invasive, no radiation, repeatable • Highly Sn (79 100%) and Sp (96 100%) Moreso in hemodynamic pts. after BAT Repeating FAST also increases Sn • May still need other imaging modalities when negative • Can be performed with equal accuracy by surgeons • Use controversial in penetrating trauma of the abdomen Only helpful if positive VERY helpful for detecting intrapericardial blood

FAST Advantages Flaws Repeatability It does little to evaluate or stage organ injuries and rarely dictates the management Non invasiveness Highly sensitivity in the detection of free fluid Performer dependent

Splenic Trauma • Diagnosis: • CT with IV contrast • Noninvasive, highly accurate, easily identifies and quantifies extent of injury, for stable patient only A: Hemoperitoneum with a liver laceration (arrow) and a shattered spleen is seen.

AAST Splenic Injury Scale Grade I Type of Injury Description of Injury Hematoma Subcapsular, < 10% Laceration Capsular tear, < 1 cm in depth Hematoma Subcapsular, 10 -50%; intraparenchymal, < 5 cm in diameter Laceration Capsular tear, 1 -3 cm in parenchymal depth, not involving trabecular vessel Hematoma Subcapsular, > 50% surface area or expanding, ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma, ≥ 5 cm or expanding Laceration > 3 cm in parenchymal depth or involving trabecular vessel IV Laceration Segmental or hilar vessels, major devascularization (>25%) V Laceration Completely shattered spleen Vascular Hilar vascular injury that devascularizes the spleen II III USED TO GUIDE THE TREATMENT PROTOCOLS BUT NOT AS AN INDICATION FOR SURGICAL

AAST Splenic Injury Scale 17 yo boy injured due to an assault. Grade I injury with subcapsular fluid occupying less than 10% of spleen’s surface area.

AAST Splenic Injury Scale 17 yo girl injured in an MVC. Grade II injury with laceration involving less than 3 cm of parenchymal depth

AAST Splenic Injury Scale 18 yo boy injured playing football. Lacerations involving more than 3 cm of parenchymal depth radiating from splenic hilum grade III laceration

AAST Splenic Injury Scale 16 yo boy injured playing hockey. Fractured spleen involving more than 25%, Grade IV splenic laceration

AAST Splenic Injury Scale 12 yo boy pedestrian struck by MV. Fractured spleen with hilar devascularization. Grade V injury.

Splenic Trauma • Complications • Pseudoaneurysms • Often asymptomatic and resolve over time • If treatment required, angiographic embolization may be used • Also occur in liver trauma A. Splenic pseudoaneurysm (arrowheads) after nonoperative treatment of blunt splenic injury. B. Successful angiographic embolization The microcatheter used to deploy the coils is marked by the arrowheads and the embolic coils are marked by the arrows.

Splenic Trauma • Complications • Pseudocysts • Rare: 0. 44% • May become large and painful • Tx: laparoscopic excision and marsupialization

Splenic Trauma • If splenectomy is indicated • Pt requires vaccinations prior to discharge • Streptococcus pneumoniae • Pneumovax 23 • Haemophilus influenzae type B • Hib vaccine • Neisseria meningitidis • Quadravalent meningococcal/diphtheria conjugate • Prophylactic antibiotics controversial • Most centers use penicillin

Splenic Trauma • Treatment • Nonoperative failure rate 2% • Risks for increased nonoperative failure rate • Bicycle related injury mechanism • More than one solid organ injury • Peaks at 4 hrs, declines at 36 hrs after admission

Contrast Blush Spleen • Contrast blush on CT scan implies: • Lower Hg. B • More likely to need operation (22% vs 4%) • Not a definite indication for operation, but indicates subset of patients who have

Spleen injury Operative management Treatment is aimed at splenic preservation, with or without surgery 1. Full mobilization of the spleen with delivery into the operative field is necessary for adequate assessment. 2. Stop the haemorrhage – by pressure, coagulation of bleeding sites, topical haemostatic agents (Fibrin Glue), splenorraphy with deep investing sutures, suture ligation of individual vessels, partial splenectomy incorporating the segmental arterial blood supply and aiming to maintain at least 30 50% of the splenic tissue.

Splenectomy 1. Exsanguinating haemorrhage, usually associated with a hilar or pedicle injury 2. The operation is likely to be prolonged by attempting a splenorraphy in a child with multiple injuries (not able to sustain)

Liver Trauma • Blunt trauma is most common cause of injury to liver • High risk due to: • Large organ, friable parenchyma, ligamentous attachments

AAST Liver Injury Grading

Liver Trauma Free fluid in the right upper quadrant on FAST scan

Types of Injury • Parenchymal damage/laceration • Subcapsular hematoma/contusion • Hepatic vascular disruption – contrast extravasation • Bile duct injury Grade IV

Diagnosis • Physical exam – • ±tachycardia, ±hypotention, peritoneal irritation • FAST – • better for unstable patients not stable enough for CT 1 • CT with contrast enhancement • determine grade and look for active extravasation

Contrast Blush Liver Contrast blush means: • more transfusion required • higher mortality (23% vs 4%) • surgical intervention warranted • mortality may be related to the other injuries

Indications for Intervention • Operate for continued blood loss with hypotension, tachycardia, decreased urine output, decreasing Hg unresponsive to IVF and p. RBC (despite blood transfusion >40 ml/kg) • Operative rates • 3 11% for multiple injuries • 0 3% for isolated liver injury • Angioembolization – not used as commonly as in adults

Bile Duct Injury • With nonoperative management, 4% risk of persistent bile leak • HIDA (hepatobiliary scintigraphy) with delayed images if bile duct injury suspected • ERCP (endoscopic retrograde pancreatcholangioography) with decompression pancreatcholangioography and stenting – can be diagnostic and therapeutic

Hepatic injury operative management • Simple suture ligation • Application of local haemostatic agents (tissue glue, gelfoam, sponge) • Perihepatic packing, using dry radiopaque marked packs to tamponade the liver between the body wall and the diaphragmatic surface • Hepatic vascular isolation • Deep mattress suture hepatorraphy • Mesh hepatorrhaphy • Omental flap to cover the laceration • Debridement • lobar or segmental resections of devitalised parenchyma • Liver transplantation • Ligation or repair damaged vessels&bile duct

Hepatic vascular isolation Vascular occlusion can safely be main tained for at least 45 min without long term sequelae (Pringle, 1908 )

APSA Guidelines APSA guidelines for hemodynamically stable children with isolated spleen or liver injury CT GRADE I II IV Days in ICU None 1 day Hospital stay 2 days 3 days 4 days 5 days Predischarge imaging None Postdischarge imaging None 3 weeks 4 weeks 5 weeks 6 weeks Activity restrictions From Stylianos S, and APSA Trauma Committee: Evidence based guidelines for resource utilization in children with isolated spleen or liver injury. J Pediatr Surg 35: 164 169, 2000

Organ Injury Scale for Kidney (AAST) grade Injury type Description of injury I Contusion Hematoma Micro/gross hematuria, urologic studies N Subcapsular, nonexpanding without parenchymal laceration II Hematoma Laceration Nonexpanding perirenal hematoma confirmed to renal retroperitoneum ˂1 cm parenchymal depth of renal cortex without urinary extravasation III Laceration ˃1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation IV Laceration Vascular Parenchymal L extending through renal cortex, medulla and collecting system Main renal artery/vein injury with contained hg V Laceration Vascular Completely shattered kidney Avulsion of renal hilum that devascularize kidney

Renal injury Surgery is warranted: - major parenchymal laceration with urinary extravasation - >20% non viable parenchyma - recurrent severe haematuria after >72 h observation In stable patients operation/nephrectomy should be avoided In high Grades RENAL SALVAGE by early vascular repair is desirable, but only 5% truly successful revascularizations after blunt trauma have been reported

Pancreas 1. Management is conservative in 40 80% 2. Surgery major injury (traumatic division or major pancreatic duct laceration), suggested by increasing abdominal tenderness, an elevated amylase on peritoneal aspiration and a persistently raised or rising serum amylase level 3. Procedure distal pancreatectomy with external drainage

Solid Organ Injury • Treatment • > 90% of hemodynamically stable pts successfully managed non operatively • Less than 10% require transfusion

u yo t o M L o t n e t is ! r he

Penetrating Abdominal Trauma • Violation of Peritoneum means risk of intra abdominal injury that requires surgery • Caused by stab wounds • Caused by gun shot wounds • Caused by other penetrating objects

Do not remove penetrating objects! Must remove in a controlled setting (Operating Room)

Management of penetrating abdominal trauma mandatory laparotomy vs selective nonoperative management

Management of penetrating abdominal trauma • Mandatory laparotomy standard of care for abdominal stab wounds until 1960 s, for GSWs until recently Now thought unnecessary in 70% of abdominal stab wounds Increased complication rates, length of stay, costs Immediate laparotomy indicated for shock, evisceration, and peritonitis

Management of penetrating abdominal trauma • Selective management used to reduce unnecessary laparotomies • Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair • Strategy depends on abdominal region: Thoracoabdomen • Nipple line to costal margin Anterior abdomen • Xiphoid to pubis Flank and back • Posterior to anterior axillary line

Management of penetrating abdominal trauma Thoracoabdomen • Big concern is diaphragmatic injury 7% of thoracoabdominal wounds • Diagnostic evaluation: CXR (hemothorax or pneumothorax) Diagnostic peritoneal lavage FAST Thoracoscopy

Thoracoabdomen

Management of penetrating abdominal trauma • Anterior abdomen Only 50 70% of anterior stab wounds enter the abdomen of these, only 50 70% cause injury requiring OR 1. is immediate lap indicated ? 2. Has peritoneal cavity been violated? 3. Is laparotomy required? Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010; 16: 609 -617

Management of PAT • Anterior abdomen Rosen’s Emergency Medicine 7 th ed

Management of penetrating abdominal trauma • Back/Flank Risk of retroperitoneal injury Intraperitoneal organ injury 15 40% Difficulty evaluating retroperitoneal organs with exam and FAST In stable pts, CT scan is reliable for excluding significant injury: Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010; 16: 609 -617

Management of penetrating abdominal trauma Gunshot wounds • Much higher mortality than stab wounds • Over 90% of pts with peritoneal penetration have injury requiring operative management • Most centers proceed to lap if peritoneal entry is suspected • Expectant management rarely done Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010; 16: 609 -617 Rosen’s Emergency Medicine 2009

Management of PAT Gunshot wounds • assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited) Rosen’s Emergency Medicine, 7 th ed. 2009

How common are injuries that require surgical repair? Anterior abdominal stab wounds: 25 33% will need a laparotomy Posterior or flank stab wounds: 15% will need a laparotomy Anterior gun shot wounds: 58 75% will need a laparotomy Posterior gun shot wounds: 33% will need a laparotomy

Absolute Indications for Laparotomy – Penetrating Abdominal Trauma 1. Shock 2. Peritonitis 3. Evisceration 4. Weapon still in situ 5. Blood out of NG tube or on rectal exam 1. Gross hematuria

Stab Wounds – Anterior Abdominal Wall Not all stab wounds to the anterior abdominal wall (AAW) will have: Violated the peritoneum Caused intraabdominal injury requiring operative repair Up to 50% of stab wounds to the AAW will not violate the peritoneum Up to 50% that violate the peritoneum do not cause injury requiring operative repair

Local Wound Exploration • To determine the depth of penetration in stab wounds • If peritoneum is violated, must do more diagnostics • Prepare, extend wound, carefully examine (No blind probing!) • Indicated for anterior abdominal stab wounds, less clear for other areas

Stab Wounds – Anterior Abdominal Wall 1. Local Wound Exploration (LWE) Sterile procedure with local anesthetic 2. Serial Physical Examinations (SPE) Done by same clinician to assess for the development of peritonitis 3. Focused Assessment with Sonography for Trauma (FAST) ‘Not indicated’ in penetrating trauma 4. Diagnostic Peritoneal Lavage (DPL) Not done in many centers

Stab Wounds – Anterior Abdominal Wall 5. Computerized Tomography (CT) Historically not used for AAW stab wounds ▪ More useful in penetrating injury to the flank and back 6. Diagnostic Laparoscopy Used to rule out: ▪ ▪ Peritoneal penetration Diaphragmatic injury on left side 7. Exploratory Laparotomy Still the gold standard in ruling out intra abdominal injury

CT Scan for Anterior Abdominal Wall Stab Wounds Not well defined, evolving modality Does not add much to serial physical exams Poor test for: Hollow viscus injuries Diaphragm injuries Use if: 1. High suspicion of solid organ injury based on wound location (R or LUQ) 2. Positive FAST exam 3. Hematuria

Pitfalls 1. DPL: Cumbersome Sensitivity poor for hollow viscus injury Different criteria for positive tests in different centers Positive test for RBC’s does not equate to needing a therapeutic laparotomy • Many solid organ injuries managed non operatively now 2. FAST (Soffer, 2004): Very limited role in penetrating abdominal trauma Rarely changes management, even if positive (1. 7%)

Pitfalls 3. Diagnostic laparoscopy: Only identifies peritoneal violation Not sensitive for hollow viscus or retroperitoneal injury Automatic conversion to laparotomy will still result in a high non therapeutic rate Still largely reserved to rule out diaphragmatic injury with left thoracoabdominal SWs • 30% will have an injury to the diaphragm – Caution: 10% develop a tension pneumothorax intraoperatively if no chest tube in place

Non Operative Management of Stab Wounds – EAST 2010 1. 2. 3. 4. Hemodynamically stable No peritonitis or diffuse abdominal pain In a center with surgical expertise Patient is evaluable* *Evaluable: absence of brain or spinal *Evaluable cord injury, intoxication or need for sedation or anesthesia • 20% of patients selected for NOM will fail (Clarke et al. , 2010)

Stab Wounds Flank and Back Laparotomy used to be standard of care used to be Fletcher, 1989 Non operative management with 3 CT in 76% of patients with SWs to flank & back Jurkovich et al, 2009 Triple contrast CT scan has replaced DPL Evaluates retroperitoneum as DPL cannot Now mandatory laparotomy replaced with triple contrast CT scan for stab wounds to flank and back

Thoracoabdominal Stab Wounds • Historically, 33% of patients with left thoracoabdominal stab wounds with have a diaphragmatic injury • Patients with left thoracoabdominal stab wounds may be observed for 12 hours • If no need for laparotomy by that time, may repair diaphragm using laparoscopic techniques

Cardiac Box Mediastinum Thoracoabdominal area

• While selective management of anterior abdominal stab wounds is appropriate. . . • Selective management of anterior abdominal Selective management GSWs is still controversial • But this can reduce the rate of non therapeutic laparotomy from 30 50% to 5 10%

Non Operative Management of Gun Shot Wounds – Guidelines (EAST) 2010 1. Hemodynamically stable 2. Tangential wound 3. No peritoneal signs 4. Consider only if patient is evaluable 5. Exception if GSW to RUQ

Non Operative Management of Gun Shot Wounds to Right Upper Quadrant (Non Tangential) Guidelines • Absolute indications: 1. 2. 3. Hemodynamically stable Patient is evaluable* Minimal to no abdominal tenderness * Evaluable: absence of brain or spinal cord injury, intoxication or need for sedation or anesthesia

How long to observe? • Patients with penetrating abdominal injuries selected for NOM should be observed for 24 hours (recommended by most centers) • They may be discharged after 24 hours in the presence of a reliable physical exam and minimal to no tenderness • The majority of asymptomatic patients who failed NOM after SWs did so within 12 hours

Laparoscopy • Most useful to evaluate penetrating wounds to thoracoabdominal region in stable pts esp for diaphragm injury: Sens 87. 5%, specificity 100% • Can repair organs via the laparoscope diaphragm, solid viscera, stomach, small bowel. • Disadvantages: poor sensitivity for hollow visceral injury, retroperitoneum Complications from trocar misplacement. If diaphragm injury, PTX during insufflation

Summary – Stab Wounds to Abdomen • Non operative management if no: Shock, peritonitis, evisceration & patient evaluable • LWE as per clinician preference LWE May discharge patient home if no fascial violation • Serial physical exams by same clinician X 24 hours Watch for peritonitis, discharge home if minimal or no pain

Summary – Stab Wounds to Abdomen • CT scan if SW to R or LUQ to rule out solid organ injury SW to flank or back as CT may rule out peritoneal violation • May send home after or. . May observe patient after CT for 24 hours nonetheless • Delayed laparoscopy after 12 hours of observation if TAA SW to left upper quadrant to identify and repair any diaphragmatic injury

Summary – GSW to Abdomen • Non operative management if no: Shock, peritonitis, evisceration & evaluable • All patients undergo CT scanning Anterior abdomen, flank or back If GSW tangential (no peritoneal breach) & no peritoneal signs, patient may be discharged If solid organ injury, may manage non operatively • Consider repeat imaging in 7 days to manage asymptomatic complications in 50% If hollow viscus injury, proceed with laparotomy If no apparent injury, observe for 24 hours

Summary – Penetrating Abdominal Trauma • Low threshold to operate • Don’t forget trauma to thoracic structures if TAA • FAST only helpful with bleeding if positive Always do a pericardial FAST if close to the box • CT only helpful with bleeding Less so with HVI • Serial physical exams helpful in all