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Abdominal injury and Management

Abdominal injury and Management. Dr.Mohammadzadeh 13 Feb 2013. Background. Traumatic injury is the leading cause of morbidity and mortality in children >1 year in U.S. Trauma to the abdomen is often initially unrecognized

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Abdominal injury and Management

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  1. Abdominal injury and Management Dr.Mohammadzadeh 13 Feb 2013

  2. Background • Traumatic injury is the leading cause of morbidity and mortality in children >1 year in U.S. • Trauma to the abdomen is often initially unrecognized • Abdominal trauma accounts for 8-10% of all trauma admissions to peds hospitals • Blunt injuries account for > 80% admits ATLS, 7th Edition, 2004

  3. Factors Unique to Pediatrics • Anatomic • Larger relative size of solid organs • Rib cage and abdominal muscles less protective • Bladder intraabdominal until adolescence • Large head: often have multisystem injury • Physiologic • Hypotension is a late finding in shock • Increased relative surface area  prone to hypothermia ATLS, 7th Edition, 2004

  4. Mechanism • Blunt abdominal trauma • Penetrating abdominal trauma • Overall about 20% require surgical operation

  5. Blunt abdominal trauma Motor vehicle crush ( MVC) injury Seat belt injury Handle bar injury Fell from height

  6. Penetrating abdominal injury • Stab wound – low energy transfer • Gun shot wound – high energy transfer

  7. Anatomy • Between diaphragm and pelvic floor • Beware of diaphragmatic injury in penetrating chest injury below the nipples (5th ICS) • Mid-axillary line • Retro-peritoneal spaces – zone I, II & III

  8. anatomy • Anterior abdomen • flank • Back • intraperitoneal contents • Retroperitoneal space contents • Pelvic cavity contents

  9. Anterior abdomen: trans-nipple line, , anterior axillary lines, inguinal ligaments and symphysis pubis. • flank: anterior and posterior axillary line ;sixth intercostal to iliac crest • Back: posterior axillary line; tip of scapula to iliac crest

  10. Peritoneal cavity: upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-small bowel, sigmoid colon • Retroperitoneal space: aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending and descending colons • Pelvic cavity: rectum, bladder, iliac vessels and internal genitalia

  11. Anatomy • Solid organs – liver, spleen, kidney (blood) • Hollow organs – blood, bile, urine, food, digestive juice, air • Remember the diaphragm which is neither solid nor hollow organ

  12. First step of Management • Resuscitation of patients with suspected abdominal injuries – same as other trauma patients • ATLS • Surgical plan

  13. Basic plan of Surgical Decision • Is there any abdominal injury? (PE) • Is intervention required? (conservative treatment + close monitoring +/- serial Ix) • Is surgery required? (interventional radiology) • Damage control or definitive surgery (correct physiology then anatomy)

  14. Assessment and diagnosis • Normal abdominal finding • Obvious injury to the abdomen eg gun shot wound • Equivocal findings requiring further investigation and re-assessment eg blunt abdominal trauma

  15. Investigations • Diagnostic peritoneal lavage DPL • FAST USG • CT scan • (Laparoscopy)

  16. DPL • Previously the standard investigation • Replaced FAST • Detect blood • Bowel content : bacteria, food particles, bile • Accuracy up to 98% • Miss diaphragmatic and retroperitoneal injury

  17. Diagnostic Peritoneal Lavage

  18. Diagnostic Peritoneal Lavage (DPL) • Amount of warmed Ringer’s lactate for lavage: • 10 ml/kg in a child • 1 liter in an adolescent/adult • Positive DPL: • >100,000 RBC/mm3 • >500 WBC/ mm3 • Gram stain with bacteria • Aspiration of gross blood, GI contents, vegetable fibers, or bile ATLS, 7th Edition, 2004

  19. FAST • Detect fluid (blood) inside peritoneal cavity • Accuracy comparable to DPL • Non invasive and repeatable • Operator dependant • Miss specific injuries • Obesity • Replace DPL in many trauma centre

  20. FAST • Focused areas of exam: • Hepatorenal fossa • Splenorenal fossa • Pericardial sac • Pelvis (pouch of Douglas)

  21. Hepatorenal view normal

  22. Hepatorenal view abnormal

  23. Splenorenal view

  24. FAST in Pediatrics • Multiple studies have prospectively evaluated FAST with CT +/- ex lap as a gold standard • Results are variable: • Sensitivity: 70-80% • Specificity: 97-100% Suthers, et al. Am Surg. 2004 Feb; 70(2): 164-7 Corbett, et al. Am J Emerg Med. 2000 May; 18(3): 244-9 Thourani, et al. J Pediatr Surg. 1998 Feb; 33(2): 322-8

  25. CAT scan • Document specific organ injury • Retro-peritoneal organs • Accurate • Haemo-dynamically stable patients • Can still miss diaphragmatic injury and bowel injury

  26. Computerized Tomography (CT) • Lifetime cancer mortality risk attributed to radiation exposure in 1 year old: • Abd CT: 0.18% • Head CT: 0.07% • 500 out of 600,000 children will die secondary to malignancy from radiation exposure Brenner, et al. Am J Roentgenol. 2001 Feb; 176(2): 289-96

  27. Computerized Tomography (CT) • Reasons to scan: • Abdominal tenderness with hematuria • Low GCS • + FAST in stable pt • Reasons not to scan: • Normal exam Richards, et al. Am J Emer Med. 1998 Jul; 16(4): 338-42

  28. Spleen/Liver • Contrast enhanced CT has 95% sensitivity and specificity for diagnosing splenic and hepatic injuries Minarik, et al. Pediatr Surg Int. 2002 Sep; 18(5-6): 429-31

  29. Bowel injury • Less sensitive/specific for hollow viscous injury • Nonspecific findings common • Serial exams most inportant

  30. Pancreas • Of 1045 children with BAT, 18 sustained injuries seen on autopsy, laparotomy, or clinically • 13/18 seen on CT with fluid in lesser sac • SN = 72%; SP = 99% Sivit, et al. Am J Roentgenol. 1992 May; 158(5): 1097-1100

  31. Renal Laceration (Grade IV)

  32. Renal Laceration (Grade IV)

  33. Renal Laceration (Grade IV)

  34. Basic plan of Surgical Decision • Is there any abdominal injury? (PE, Ix) • Is intervention required? (conservative treatment + close monitoring +/- serial Ix) • Is surgery required? (interventional radiology) • Damage control or definitive surgery (correct physiology then anatomy)

  35. Surgical decision • Normal abdominal finding • Obvious injury to the abdomen • Equivocal abdominal findings

  36. Normal abdominal finding • Re-assessment and physical finding by same experienced surgeon in haemo-dynamically normal is usually sufficient • ? CAT scan before other extra-abdominal surgery in awake and alert patients • FAST or DPL in unstable patients

  37. Surgical decision • Normal abdominal finding • Obvious injury to the abdomen • Equivocal abdominal findings

  38. Obvious injury to the abdomen • Mostly applied to penetrating injury • Virtually all penetrating abdominal injury should be “explored” promptly, especially in the presence of hypotension • Local wound exploration • Laparoscopy / laparotomy • Gun shot wound - laparotomy • CAT scan

  39. Surgical decision • Normal abdominal finding • Obvious injury to the abdomen • Equivocal abdominal findings

  40. Equivocal abdominal findings • Further investigation very much depends on haemo-dynamic status of the patients • Haemodynamically normal: reassessment , CAT scan, other investigation

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