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Trauma Patient with Open abdomen

Case History. 52 y.o. male in high speed MVCED / Radiographic findings:Grade III Liver LacerationGrade IV Spleen lacerationOpen book pelvis fracture. Emergent Interventions. External FixatorDamage Control LaparotomySplenectomySuture hepatorrhaphy

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Trauma Patient with Open abdomen

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    1. Trauma Patient with Open abdomen Courtesy of: Michael Cheatham, MD WSACS website

    3. Emergent Interventions External Fixator Damage Control Laparotomy Splenectomy Suture hepatorrhaphy “Open Abdomen” dressing with vacuum style temporary closure

    4. Initial ICU Evaluation MAP=76 HR=124 T=34.5° C IAP=14 APP=62 (APP=MAP-IAP) Lactate 3.2 Coagulopathic, Low Plts, Anemic Abdominal dressing soft, draining serosanginous fluid

    5. What should be done? Warm the patient Transfuse with appropriate blood products

    6. 6 hour ICU Evaluation MAP=70 HR=114 T=36.5° C IAP=24 APP=46 (APP=MAP-IAP) Lactate 6.5 UOP < 30 cc/ hour, PIP = 60 cm H2O Abdominal dressing firm and bulging

    7. What is wrong? Recurrent Abdominal compartment syndrome Definition: The redevelopment of ACS following previous surgical or medical treatment to prevent or treat ACS. The is no such thing as an “open abdomen” outside the O.R. – just an expanded abdomen with “temporary abdominal closure.”

    8. Treatment 6 hours into ICU Vacuum pack is removed Dramatic bowel evisceration Replaced with plastic silo dressing

    9. Post-dressing expansion MAP=70 HR=96 T=36.7° C IAP=12 APP=58 (APP=MAP-IAP) UOP >100 cc/ hour PIP = 30 cm H2O

    10. 24 hours into ICU stay Worsened bowel edema However: MAP = 79 IAP = 12 APP = 67 Lactate = 1.9

    11. Remaining ICU course Day 2-4: Visceral edema decreases IAP drops further, VSS remain stable Day 7: Abdomen is closed primarily Day 8: Transfer to floor

    12. Case points Recurrent ACS: There is no such thing as an “open abdomen” Just an “expanded abdomen” that is re-dressed Open abdominal management = High risk of capillary leak and recurrent ACS All patients who require open abdomens require mandatory serial abdominal pressures to allow early detection of recurrent ACS.

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