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  เจ็บฟรี, เสียหน้า, เสียเวลา

 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 Class I Class II Class III Class IV

For 70 kg male 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 Repeat FAST bleeding, if not Observe found DPA +/- EL 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 DPL  Observe 24 hr  Unstable with other  Ideal same surgeon cause bleeding  Frequent check V/S  Abdominal sigh every  Stable R/O hollow 4 hr viscus or diaphragmatic injury  Persist local symptom => other modality evaluated FAST  Not recomment Routine laparotomy both stab and GSW

Increase conservative in stab wound Laparotomy in GSW

More conservative in GSW  Not routine in  Triple contrast anterior stab  Wound tract wound evaluated  Free air, free fluid  Recommend in  Contrast - Stab wound at extravasate flank and back (15%  Intraluminal require surgical repair) contrast leak - GSW  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 อุดรูรั่วและเติมน ้าให้ทัน ถ้าตุ่มแห้ง => เลือดหมดตัว => 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  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

Manual of Definitive Surgical Trauma Care, Boffard 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 Trauma Mattox Edition6 Laparotomy or CT head first ?? Laparotomy in patient with GCS 2T ?? 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 Pancreatic Inj

Trauma Mattox Edition6

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 Depend on  Primary repair  Position of injury  Resection => Stomach, Small +/- anastomosis bowel, Colon +/- proximal  Severity of injury diversion  Contamination  Diversion only  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