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CASE PRESENTATION AND SHARING OF INFORMATION ON ABDOMINAL TRAUMA

CASE PRESENTATION AND SHARING OF INFORMATION ON ABDOMINAL TRAUMA. by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center. M.S., 28/M TONDO, MANILA. CHIEF COMPLAINT : STAB WOUND. HISTORY OF PRESENT ILLNESS:.

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CASE PRESENTATION AND SHARING OF INFORMATION ON ABDOMINAL TRAUMA

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  1. CASE PRESENTATION AND SHARING OF INFORMATION ON ABDOMINAL TRAUMA by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center

  2. M.S., 28/M TONDO, MANILA

  3. CHIEF COMPLAINT: STAB WOUND

  4. HISTORY OF PRESENT ILLNESS: • A few minutes PTA  the patient was allegedly stabbed with a knife by an unknown drunk male assailant.

  5. PAST MEDICAL Hx: • No known co-morbidities • FAMILY Hx: - No heredofamilial disease noted

  6. PERSONAL/SOCIAL Hx: occasional smoker and alcoholic beverage drinker

  7. PHYSICAL EXAMINATION: BP= 90/70 CR=105 RR= 28 T=36.5 HEENT: pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPC HEART: adynamic precordium, NRRR, no murmur

  8. PHYSICAL EXAMINATION: CHEST AND LUNGS: Symmetric chest expansion, no retractions, clear and equal breath sounds (+) stab wound, 10th ICS, MAL, Right

  9. PHYSICAL EXAMINATION: HEART: adynamic precordium, NRRR, no murmur ABDOMEN:Flat, (+) muscle guarding at RUQ and epigastric area; direct tenderness at RUQ and epigastric area EXTREMITIES: full equal pulses, No edema

  10. SALIENT FEATURES: • 28 y/o, M • Stab wound: 10th ICS MAL, Right • BP = 90/70 • Symmetric chest expansion, no retractions, clear and equal breath sounds • (+) muscle guarding on RUQ and epigastric areas • (+) direct tenderness RUQ and epigastric areas

  11. Stab wound at the 10th ICS, MAL, Right Thoracoabdominal junction Abdominal Thoracic Non-penetrating Penetrating

  12. Clinical Diagnosis:

  13. BASIS: Patient presenting with: • Symmetric chest expansion, no retractions, clear and equal breath sounds • (+) stab wound, 10th ICS, MAL, Right • (+) muscle guarding on RUQ and epigastric areas • (+) direct tenderness RUQ and epigastric areas

  14. Do I need a para-clinical diagnostic procedure? YES

  15. Paraclinical Diagnostic Procedure

  16. Paraclinical Diagnostic Procedure CXR upright: • (-) pneumoperitoneum • (-) pneumohemothorax

  17. Pre Treatment Diagnosis

  18. GOALS OF TREATMENT 1. Identification and repair of injured organ/s • Resolve source of peritonitis • Restoration of vascular perfusion 4. Minimal complications 5. Live patient

  19. Treatment Options

  20. Treatment Plan Exploratory Laparotomy

  21. PREOPERATIVE PREPARATION • Psychosocial support • Optimize patient • Adequate hydration • Adequate antibiotic coverage • Prepare materials

  22. OPERATIVE TECHNIQUE • Patient in a supine position under GETA • Asepsis and antisepsis techniques observed • Sterile drapes placed • Midline incision done from the xiphoid up to mid pubic area carried down up to the subcutaneous

  23. OPERATIVE TECHNIQUE • Peritoneum entered by incising along the linea alba • Intraoperative findings noted: • Approximately 2 liters of intraperitoneal clotted blood evacuated • 2 cm Grade II Hepatic Laceration, segment 7 • No diaphragmatic laceration • GI tract examined for other injuries

  24. GOALS OF TREATMENT • Repair of liver injury • Achieve hemostasis • Prevent further complications

  25. TREATMENT OPTIONS

  26. TREATMENT PLAN Primary repair, without hepatotomy

  27. OPERATIVE TECHNIQUE • Primary repair of liver injury using horizontal mattress sutures with chromic 4-0 • Peritoneal lavage done • GI tract re-examined for other injuries • Hemostasis secured • Layer by layer closure • DSD

  28. FINAL DIAGNOSIS Stab Wound, 10th ICS MAL, Right Grade II Hepatic Laceration, Segment 7

  29. POST-OP CARE • Sufficient analgesia • Nutrition • Wound care • Monitoring of complications and treat as indicated

  30. DISCHARGE ADVISE • Continue medications (Cloxacillin) at home until day 7 • Daily wound care • Resume normal daily activities • Follow up after a week or earlier if any problem arises

  31. SHARING OF INFORMATION

  32. HEPATIC INJURIES • Liver injury occurs in approximately 5% of all trauma admissions • Size • Anatomic location • Two types of liver injury • Blunt • Penetrating

  33. Anatomy • caudate/Spigel lobe • left posterolateral segment • left anterolateral segment • IVa) left superomedial segment • IVb) left inferomedial segment • right anteroinferior segment • right posteroinferior segment • right posterosuperior segment • right anterosuperior segment

  34. Anatomy • caudate/Spigel lobe • left posterolateral segment • left anterolateral segment • IVa) left superomedial segment • IVb) left inferomedial segment • right anteroinferior segment • right posteroinferior segment • right posterosuperior segment • right anterosuperior segment

  35. GRADING OF LIVER INJURIES

  36. GRADING OF LIVER INJURIES

  37. CRITERIA FOR NON OPERATIVE MANAGEMENT • The patient is hemodynamically stable (SBP > 100mmHg and PR < 100bpm)4 • Abdominal pain and/or tenderness are not persistent • Absence of other peritoneal injuries requiring laparotomy • <4 units of pRBCs required • <500ml of hemoperitoneum on abdominal CT • Simple hepatic laceration or intrahepatic hematoma on abdominal CT R. D. Brammer, S. R. Bramhall, D. F. Mirza, A. D. Mayer, P. McMaster and J. A. C. Buckels. A 10-year experience of complex liver trauma. British Journal of Surgery 2002, 89, 1532±1537 .

  38. COMPLICATIONS • Bleeding • Hemobilia – jaundice, RUQ pain, falling Hct , UGIB • Bilhemia – bilous venous blood dissolved in bloodstream. Increase in serum bilirubin with normal LFT • Biliary Fistula

  39. References • Udobi KF, Rodriguez A, Chiu WC et al. 'Role of Ultrasonography in Penetrating Abdominal Trauma: A Prospective Clinical Study'. J Trauma 2001;50:475-479 • Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients. Radiology. 2004;231:775-84 • Kirkpatrick AW, Sirois M, Ball CG et al. 'The hand-held ultrasound examination for penetrating abdominal trauma'. Am J Surg. 2004;187:660-5 • American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Student Manual. 5th ed. Chicago, Illinois: American College of Surgeons, 1995.

  40. References 6. R. D. Brammer, S. R. Bramhall, D. F. Mirza, A. D. Mayer, P. McMaster and J. A. C. Buckels. A 10-year experience of complex liver trauma. British Journal of Surgery 2002, 89, 1532±1537

  41. MCQ # 1 A 23/f arrived at the emergency room with a stab wound at the epigastric area. What segment of the liver would have the greatest chance for injury? • Segment 1 • Segment 4 • Segment 2 • Segment 7

  42. MCQ # 1 A 23/f arrived at the emergency room with a stab wound at the epigastric area. What segment of the liver would have the greatest chance for injury? • Segment 1 • Segment 4 • Segment 2 • Segment 7

  43. MCQ #2 Intraoperative findings revealed a laceration at segment V about 4 cm deep with a subcapsular/central hematoma 1- to 3-cm diameter. What would be your liver injury grade? • Grade I • Grade II • Grade III • Grade IV

  44. MCQ #2 Intraoperative findings revealed a laceration at segment V about 4 cm deep with a subcapsular/central hematoma 1- to 3-cm diameter. What would be your liver injury grade? • Grade I • Grade II • Grade III • Grade IV

  45. MCR # 1 A 24 y/o man, three weeks post op for hepatic trauma, complains of episodes of hematochezia and black tarry stools. What complication(s) of hepatic surgery can we consider? (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) • Bilhemia • Biliary Fistula • Liver Hematoma • Hemobilia

  46. MCR # 1 A 24 y/o man, three weeks post op for hepatic trauma, complains of episodes of hematochezia and black tarry stools. What complication(s) of hepatic surgery can we consider? (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) • Bilhemia • Biliary Fistula • Liver Hematoma • Hemobilia

  47. MCR # 2 The following are the criteria for non-operative management of liver injuries. (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) • The patient is hemodynamically stable • Abdominal pain and/or tenderness are not persistent • Absence of other peritoneal injuries requiring laparotomy • ≤ 750cc hemoperitoneum by CT scan

  48. MCR # 2 The following are the criteria for non-operative management of liver injuries. (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) • The patient is hemodynamically stable • Abdominal pain and/or tenderness are not persistent • Absence of other peritoneal injuries requiring laparotomy • ≤ 750cc hemoperitoneum by CT scan

  49. MCR # 3 A 40 y/o man, 6 months post-op for hepatic trauma, had an incidental finding of an elevated serum bilirubin. Liver function tests however showed normal values. He might be suffering from? (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) • Hemobilia • Biliary Fistula • Hepatic abscess • Bilhemia

  50. MCR # 3 A 40 y/o man, 6 months post-op for hepatic trauma, had an incidental finding of an elevated serum bilirubin. Liver function tests however showed normal values. He might be suffering from? (a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all) • Hemobilia • Biliary Fistula • Hepatic abscess • Bilhemia

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