PONGSASIT SINGHATAS, M.D. Department of Surgery Faculty of Medicine, Ramathibodi Hospital Mahidol University

PONGSASIT SINGHATAS, M.D. Department of Surgery Faculty of Medicine, Ramathibodi Hospital Mahidol University

Patient survive Low morbidity GOOD JUDGMENT COMES FROM EXPERIENCE EXPERIENCE COMES FROM BAD JUDGMENT

Airway and Breathing first Solid organ and Vascular injury => C Hollow viscous injury => Sepsis

Investigate and assessment of abdomen base on three group 1)Normal abdomen 2)Equivocal require investigation 3)Obvious abdominal injury Diagnosis modalities 1) PE 2) DPL 3) FAST 4) CT scan 5) Diagnostic laparoscope

Hemodynamically normal patient Full evaluation and decision to surgery or non-operative management Hemodynamically stable patient Will benefit from investigation aimed to - Patient bled into abdomen? - Bleeding has stopped? - Hollow viscous injury?

Hemodynamically unstable patient Try to define bleeding is taking place e.g. pelvis or abdominal cavity FAST quicker than DPL but operator dependence Negative DPL => very clear that the intra abdominal bleeding is unlikely in unstable patient

Negative Exporation => Survive Positive Unexploration => Dead เจ บฟร, เส ยหน า, เส ยเวลา Operative complication (GA, wound, adhesion) Communication with patient and relative Except Negative Exploration in Pelvic Fx

Unstable vital sign with abdominal cause or Peritonitis (Diffuse Abdominal tender)

Bowel content Bile Urine Pancreatic juice Blood Difficult to exam in Head injury Cord injury Intoxication

Adequate analgesia Never mask abdominal symptom Make abdominal pathology easier to assess - Clear physical sign - Co-operative patient

FAST in unstable patient Positive => explore laparotomy Equivocal => DPL/DPA or explore laparotomy Negative => Find other bleeding, if not found DPL/DPA or explore laparotomy No ultrasound available =>DPL/DPA Not sent unstable patient to CT room Abdominal sign Pelvic fracture with lower abdominal sign

CT or FAST not available No other source in hemodynamic unstable Distinguish blood from other type of fluid DPA => gross blood in unstable patient Trauma Mattox Edition6

Not BP only Hypertensive patient?? Sign of poor tissue perfusion 4 classification of hypovolemic shock And Responsibility after fluid resuscitation

For 70 kg male Class I Class II Class III Class IV

2000 mlof isotonic solution in adult; 20 ml/kg in children

Solid organ injury => liver, spleen, kidney, pancreas Vascular injury with interventionist Need ICU Need OR available Need Surgeon available Necessary to CT scan??

- Triple contrast - Solid parenchymal organ injury - Free air (Plain film abdomen) - Free fluid with Hounsfield Units - Contrast extravasations (lumen and vessel) - Injury grading Limitation - Hollow viscus - Mesenteric injury - Diaphragmatic injury - Bladder injury (need CT cystogram)

Trauma Mattox Edition6

Unstable Stable FAST Positive EL CT FAST Equivocal DPA +/- EL CT FAST Negative Find other bleeding, if not found DPA +/- EL Repeat FAST Observe CT?? CT not available???

Not routinely Stab wound Anterior abdomen No indication in Flank or back Under local anesthesia Positive => Penetration of posterior fascia Rarely practice in trauma center Trauma Mattox Edition6

Serial PE Observe 24 hr Ideal same surgeon Frequent check V/S Abdominal sigh every 4 hr Persist local symptom => other modality evaluated DPL Unstable with other cause bleeding Stable R/O hollow viscus or diaphragmatic injury FAST Not recomment

Routine laparotomy both stab and GSW Increase conservative in stab wound Laparotomy in GSW More conservative in GSW

Not routine in anterior stab wound Recommend in - Stab wound at flank and back (15% require surgical repair) - GSW Triple contrast Wound tract evaluated Free air, free fluid Contrast extravasate Intraluminal contrast leak Bowel wall defect

Trauma Mattox Edition6

Peritonitis Unstable vital sign Blood replacement??

Most common cause in trauma Presumed hemorrhagic shock until proven otherwise Fluid resuscitation in early signs and symptoms of blood loss Principle is Stop the bleeding and replace the volume loss

Whole blood is superior than component therapy PRBC:FFP ratio of 1:1 or 2:1 Platelet require in blood loss greater than 1.5 blood volume

อ ดร ร วและเต มน าให ท น ถ าต มแห ง => เล อดหมดต ว => ตาย Exsanguination = Extensive Hemorrhage

- Large syringe connect to pressure source (human hand) - IV pressure bag - Pneumatic external pressurized intravenous infusion system Increasing hematocrit and decreasing temperature => Increase blood viscosity

Manual of Definitive Surgical Trauma Care, Boffard Controlled resuscitation, balance resuscitation, permissive hypotension Keep SBP 80-90 mmhg or 100 mmhg if head injury is suspected Penetrating trauma with hemorrhage No evidence in blunt trauma

Manual of Definitive Surgical Trauma Care, Boffard Delay aggressive fluid resuscitation until definitive control Prevent additional bleeding Balance of organ perfusion and Risk of rebleeding (accept a low normal blood pressure)

Manual of Definitive Surgical Trauma Care, Boffard Desire to reassess the intra-abdominal content (directed re-look) Evidence of decline of physiology reverse 1)Initial body temperature < 34 C 2)Initial acid-base status - Arterial ph <7.2 - Serum lactate > 5 mmol/l - Base deficit <-15 mmol/l in patient <55 years or <-6 mmol/l in patient >55 years

3)Onset coagulopathy PT >16 sec or PTT >60 sec >50% of normal 4)Other condition - >10 unit blood - SBP <90 mmhg more than 60 min - Operating time >60 min Control 1. Bleeding 2. Contamination

Thoracotomy if indication Laparotomy if indication In unstable patient, what is first? => depend on ICD content => prep both chest and abdomen

Diaphragmatic injury Difficult to diagnosis Both hemothorax and hemoperitonem in one penetrate wound Bowel content or NG tube at chest (Lt) from film chest in blunt Should be repair by non absorbable Laparoscopic diagnosis and repair is standard Can repair from thoracotomy or laparotomy

11 in 28 (39%) mortality in unstable pelvic Fx with laporotomy FAST positive => retroperitoneal hematoma passes into abdominal cavity J.K. Bryceland, Injury, Int. J. Care Injured 2008 31 in 80 unstable pelvic Fx patients with free fluid and undervent laparotomy 1 in 31 patient show retroperitoneal hemaotoma alone Mortality rate 35% in laparotomy group Steffen R, J Trauma.2004;57:278 286.

Unstable Trauma Mattox Edition6

Secondary brain injury - Hypovolemic shock - Polycompartment syndrome Severe HI associated DIC - Now, conservative in solid organ injury is accept - Threshold for laparotomy lower than non HI Laparotomy or CT head first?? Laparotomy in patient with GCS 2T?? Trauma Mattox Edition6

Trauma Mattox Edition6

Technique for temporary control of hemorrhage Perihepatic packing Electrocautery or argon beam coagulator Pringle s manoeuvre Hemostatis agent and glues Hepatic suture -> large curve needle Chromic

Technique for temporary control of hemorrhage Finger fracture hepatotomy and vessel ligation Tract temponade balloon (Sengstaken tube) Tractotomy and direct suture Mesh wrap Hepatic artery ligation

Technique for temporary control of hemorrhage Hepatic resection Hepatic vascular isolation Atriocaval shunt Veno-venous bypass

Hepatic vascular isolation Pringle s manoeuvre Clamp IVC above Rt kidney (Suprarenal) Clamp IVC above live (Suprahepatic)

Atriocaval shunt

Good exposure Proximal and distal control Anatomical distortion from hematoma Active bleeding - Pressure first - Supraceliac control or Lt anterolateral thoracotomy in aorta injury - Supradiaphragmatic control in IVC Manual of Definitive Surgical Trauma Care, Boffard

Retroperitoneal organ In early of injury, abdominal exam is difficult FAST or DPL maybe negative Retorperitoneal free air in plain film or CT) High mortality if delay diagnosis Should be Kocherization and open lesser sac in blunt abdominal injury

Duodenal Inj Trauma Mattox Edition6

Trauma Mattox Edition6 Pancreatic Inj

Non-operative Indication for surgery follow non-operative Hemodynamic instable Evidence of continued splenic hemorrhage Associate intra-abdominal injury requiring surgery Replacement of more than 50% of blood volume

Spleen not active bleeding -> left alone Splenic surface bleeding only -> packing, diathemy or fibril glue Minor lacerations -> absorbable suture use pledget, omental patch may be place

Splenic tears 1) Mesh wrap -> absorbable mesh e.g. Vicryl wrap from hilum and around parenchyma 2) Partial splenectomy -> ligating segmental vessel at hilum and seen demarcation ischemic pole 3) Splenectomy

Option Primary repair Resection +/- anastomosis +/- proximal diversion Diversion only Depend on Position of injury => Stomach, Small bowel, Colon Severity of injury Contamination Patient status Can not conservative Need to Laparotomy

Aim of trauma is patient survive Different resource => different judgment Now, try conservative but patient safety is most important Don t forget call for help Damage control if indication