MEDICAL MANAGEMENT OF ABDOMINAL TRAUMA LUIS H. TELLO MV, MS, DVM, COS Portland Hospital Classic International Medical Advisor Banfield Pet Hospital
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
MASSIVE ABDOMINAL BLUNT TRAUMA
ABDOMINAL TRAUMA PHYSIOPATHOLOGY Combining forces : Compression Extension Separation Kinetic energy is transferred to abdominal organs The transmitted energy overcomes organ resistance
ABDOMINAL TRAUMA PHYSIOPATHOLOGY The energy dissipated in the abdomen is: KE= MV 2 2 KE: Kinetic Energy M : Mass V : Velocity
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
ABDOMINAL TRAUMA
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
Massive Abdominal Trauma First dogs used for hunting
Traumatic Hemobadomen almost always is better to go to Sx with the exception of when is not!!
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
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%).
Anatomy: Trauma de abdomen
Hemoabdomen
Types of trauma Closed Open
Penetranting Trauma Bullets, arrows, impalement, bites, Caudal lesions in the thorax may be abdominal
Closed abdominaltrauma: Approach PE is difficult and equivocal Key: 5 signs Temperature Pulse Respiratory rate Blood Pressure Pain Score
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
ABDOMINAL TRAUMA DIAGNOSTIC PROCEDURES: ABDOMINOCENTESIS PERITONEAL LAVAGE ABDOMINAL ECOTOMOGRAPHY ABDOMINAL RADIOGRAPHY C.A.T. SCAN
ABDOMINAL TRAUMA ABDOMINOCENTESIS:
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
ABDOMINAL TRAUMA PERITONEAL LAVAGE: 20-22 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
ABDOMINAL TRAUMA PERITONEAL LAVAGE : evaluation PCV PROTEINS CITOLOGY BUN - CREATININ BILIRRUBIN BOYSCOUT TEST
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
ABDOMINAL TRAUMA POSITIVE LAVAGE: HEMOPERITONEUM PCV > than peripherical Spleen has a higher PCV than blood The peritoneum absorbs water and electrolytes More than 100.000 erythrocytes/ml More than 500 leukocytes/ml Can it be read through the tube??
HEMOPERITONEUM MANY POINTS OF VIEW!!!!
Lab Data Base Hct y Hb Glycemia Creatinine Ca - Mg CPL Proteines UA Coagulation profile Blood gaseselectrolytes
Images Radiographs Limited value: serosal detail, free gas Hernias Evidence of bone/joint/soft tissue lesions
Trauma Abdomen You may think on... Pneumocystography Contrast studies
Trauma abdomen Hemoabdomen Pneumoperitoneo
Radiographs
Ultrasound: FAST JAVMA. 2004 Oct 15;225(8):1198-204 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
Tap the abdomen Easy, fast, cheap High percentage of false negatives Should be more than 5 ml/kg of free fluid
Abdomen Trauma Abdominal centesis: 4 quadrants
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
Materials
Mini Laparotomy
Entonces.cortamos o no?
Gross examination RED: Hemorrhage GREEN:Gallbladder Biliary tract YELLOW: Urinary tract BROWN GI tract
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..
No Sx Tx of HEMOBANDOMEN) FLUID Tx (NO EXCESSIVELY AGGRESSIVE) PLASMA Coagulation factors Pain management Sedation Oxygen ICU MONITORING
Sx: Damage control Control of hemorrhage Explore Control of contamination Packing Fast closure
Hemorrhage control Pringle maneuver
Packing
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
UROPERITONEUM
UROPERITONEUM Massive rupture is frequent in blunt trauma with full bladder It can be diagnosed with contrasted X-rays : Excretion Nephrogram Contrasted Cystogram Pneumocystogram
UROPERITONEUM Massive rupture is frequent in blunt trauma with full bladder It can be diagnosed with contrasted X-rays : Excretion Nephrogram Contrasted Cystogram Pneumocystogram
UROPERITONEUM SURGICAL THERAPY
THANKS