MEDICAL MANAGEMENT OF ABDOMINAL TRAUMA. LUIS H. TELLO MV, MS, DVM, COS Portland Hospital Classic International Medical Advisor Banfield Pet Hospital

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1 MEDICAL MANAGEMENT OF ABDOMINAL TRAUMA LUIS H. TELLO MV, MS, DVM, COS Portland Hospital Classic International Medical Advisor Banfield Pet Hospital

2 ABDOMINAL TRAUMA 70-80% of multiple trauma patients 55% of motor vehicle accidents Undiagnosed in human trauma patients 40% of them are asymptomatic The most frequent are BLUNT TRAUMA PENETRATING TRAUMA

3 MASSIVE ABDOMINAL BLUNT TRAUMA

4 ABDOMINAL TRAUMA PHYSIOPATHOLOGY Combining forces : Compression Extension Separation Kinetic energy is transferred to abdominal organs The transmitted energy overcomes organ resistance

5 ABDOMINAL TRAUMA PHYSIOPATHOLOGY The energy dissipated in the abdomen is: KE= MV 2 2 KE: Kinetic Energy M : Mass V : Velocity

6 ABDOMINAL TRAUMA ASSOCIATED CLINICAL SIGNS: Abdomen Haematoma Perineal Haematoma (Retroperitoneal) Abdominal tenderness (Pain) Hemodynamic instability (Hemorrhage) Pelvic fractures - Caudal ribs Lumbar spine injuries Abdominal distention

7 ABDOMINAL TRAUMA

8 ABDOMINAL DISTENTION: ABDOMINAL Sensitive parameter in humans Associated to pain No informatio1n in Veterinary Medicine Each inch of increment in abdominal perimeter: 500cc of free intraabdominal blood TRAUMA

9 Massive Abdominal Trauma First dogs used for hunting

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11 Traumatic Hemobadomen almost always is better to go to Sx with the exception of when is not!!

12 Hemoabdomen: Epidemiology Incidence 11 % 71 % are closed trauma cases, 29% open or penetrating 20 % of patients that are moved to Sx have lesions NO DETECTED PREVIOUSLY Humans: 40% is asymptomatic

13 Cats may have spontaneous hemoabdomen! JVECCS 2010, Drobatz, et al Sixteen cases of feline, non-traumatic hemoperitoneum were evaluated retrospectively. The causes of hemoperitoneum were hepatic neoplasia (31%), hepatic necrosis (19%), hepatic amyloidosis (13%), non hepatic neoplasia (13%), hepatopathy (6%), hepatic rupture (6%), necrotic/hemorrhagic cystitis (6%), and ruptured bladder (6%).

14 Anatomy: Trauma de abdomen

15 Hemoabdomen

16 Types of trauma Closed Open

17 Penetranting Trauma Bullets, arrows, impalement, bites, Caudal lesions in the thorax may be abdominal

18 Closed abdominaltrauma: Approach PE is difficult and equivocal Key: 5 signs Temperature Pulse Respiratory rate Blood Pressure Pain Score

19 Determine: Goals during initial assessment There is an intraabdominal lesions Require medical or surgical Tx Find out signs of the TRIADE of DEATH ACIDOSIS HYPOTHERMIA COAGULOPATHY

20 ABDOMINAL TRAUMA DIAGNOSTIC PROCEDURES: ABDOMINOCENTESIS PERITONEAL LAVAGE ABDOMINAL ECOTOMOGRAPHY ABDOMINAL RADIOGRAPHY C.A.T. SCAN

21 ABDOMINAL TRAUMA ABDOMINOCENTESIS:

22 ABDOMINAL TRAUMA ABDOMINOCENTESIS: 20-22G Needle or Butterfly catheter+syringe Medium line caudal to umbilical scar Get inside, infusing saline 0,9% Negative: 4 quadrants puncture Negative: peritoneal lavage

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24 ABDOMINAL TRAUMA PERITONEAL LAVAGE: G needle or butterfly catheter Central medium caudal to umbilical scar Infuse 20 ml/kg warm saline NaCl 0,9% Rotate or walk the patient Obtain a few ml for evaluation

25 ABDOMINAL TRAUMA PERITONEAL LAVAGE : evaluation PCV PROTEINS CITOLOGY BUN - CREATININ BILIRRUBIN BOYSCOUT TEST

26 ABDOMINAL TRAUMA BOY SCOUT TEST: PUT A DROP OF PERITONEAL LAVAGE FLUID ON A MICROSCOPE SLIDE HEAT TO DIRECT FLAME AMMONIA RELEASE? URINE!! SCOUTS PUT OUT FIRES WITH URINE

27 ABDOMINAL TRAUMA POSITIVE LAVAGE: HEMOPERITONEUM PCV > than peripherical Spleen has a higher PCV than blood The peritoneum absorbs water and electrolytes More than erythrocytes/ml More than 500 leukocytes/ml Can it be read through the tube??

28 HEMOPERITONEUM MANY POINTS OF VIEW!!!!

29 Lab Data Base Hct y Hb Glycemia Creatinine Ca - Mg CPL Proteines UA Coagulation profile Blood gaseselectrolytes

30 Images Radiographs Limited value: serosal detail, free gas Hernias Evidence of bone/joint/soft tissue lesions

31 Trauma Abdomen You may think on... Pneumocystography Contrast studies

32 Trauma abdomen Hemoabdomen Pneumoperitoneo

33 Radiographs

34 Ultrasound: FAST JAVMA Oct 15;225(8): Evaluation of focused assement with sonography for trauma protocol to detect free abdominal fluid in dogs involved in motor vehicle accidents Boysen S, Rozanski E, Tidwell,A 4 points

35 Tap the abdomen Easy, fast, cheap High percentage of false negatives Should be more than 5 ml/kg of free fluid

36 Abdomen Trauma Abdominal centesis: 4 quadrants

37 DPL: Diagnostic Peritoneal Lavage Negative Tap Introduce 20ml/kg warm saline Very sensitive Collect fluid in tubes: with and without EDTA Do not use for Retroperitoneal lesions, Pregnant Dilated GI

38 Materials

39 Mini Laparotomy

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45 Entonces.cortamos o no?

46 Gross examination RED: Hemorrhage GREEN:Gallbladder Biliary tract YELLOW: Urinary tract BROWN GI tract

47 So.cut or not? The key seems to be on the patient No response to Tx Worsening hypotension Mentation worsening Drop on the Hct (20%) If you are not sure..

48 No Sx Tx of HEMOBANDOMEN) FLUID Tx (NO EXCESSIVELY AGGRESSIVE) PLASMA Coagulation factors Pain management Sedation Oxygen ICU MONITORING

49 Sx: Damage control Control of hemorrhage Explore Control of contamination Packing Fast closure

50 Hemorrhage control Pringle maneuver

51 Packing

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54 Post Sx Fluids, Atb, Nutrition Check Hct, Proteines, Albumine Monitor Blood Pressure Monitor ECG Monitor Urine production DO NOT FEEL SAFE BEFORE 72 HOURS POST SX

55 UROPERITONEUM

56 UROPERITONEUM Massive rupture is frequent in blunt trauma with full bladder It can be diagnosed with contrasted X-rays : Excretion Nephrogram Contrasted Cystogram Pneumocystogram

57 UROPERITONEUM Massive rupture is frequent in blunt trauma with full bladder It can be diagnosed with contrasted X-rays : Excretion Nephrogram Contrasted Cystogram Pneumocystogram

58 UROPERITONEUM SURGICAL THERAPY

59 THANKS