Rajiv Gandhi University of Health Sciences s36

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE KARNATAKA

ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DR. RAMMOHAN. S 1 Name of the candidate and : M.S. GENERAL SURGERY Address(Block letters) MAHADEVAPPA RAMPURE MEDICAL COLLEGE GULBARGA- 585105 KARNATAKA Permanent Address : DR .RAMMOHAN .S S/O DR.G.SUNDARAMOORTHY 9/21,ANNAMALAI NAGAR, SEELANAICKENPATTI, SALEM - 636201 : H.K.E SOCIETY’S MAHADEVAPPA RAMPURE MEDICAL 2 Name of the institution COLLEGE, GULBARGA-585105

3 Course of study and subject. : M.S. GENERAL SURGERY

4 Date of Admission : 17/8/2013 : CLINICAL STUDY, EVALUATION AND MANAGEMENT OF BLUNT ABDOMINAL TRAUMA-HOLLOW VISCUS AND SOLID ORGAN INJURIES AT BASAVESHWAR 5 Title of Topic TEACHING & GENERAL HOSPITAL ATTACHED TO MAHADEVAPPA RAMPURE MEDICAL COLLEGE,GULBARGA 6 Brief resume of work 6.1 Need for the study: Abdominal trauma is one of the most common causes among injuries caused mainly due to road traffic accidents and urban violence. The rapid increase in motor vehicles and its afternath has caused rapid increase in number of victims to blunt abdominal trauma. Blunt injury of abdomen is also a result of fall from height, assault with blunt objects, sports injuries, industrial mishaps, and fall from riding bicycle. Abdominal trauma continues to account for a large number of trauma related injuries and death. Blunt abdominal trauma is usually not obvious. Hence often missed, unless, repeatedly looked for. Due to inadequate treatment of the abdominal injuries, most of the cases are fatal. The knowledge in the management of blunt abdominal trauma is progressively increasing due to in-patient data gathered from different parts of the world. In spite of the best techniques and advances in diagnostic tools and supportive care, the morbidity and mortality remains large. The reason for this could be interval between trauma and hospitalization, delay in diagnosis, lack of appropriate surgical treatment, post operative complications and associated trauma to head, thorax and extremities. Rapid resuscitation is necessary to save the unstable but salvageable patient with abdominal trauma. Accurate diagnosis and avoidance of needless surgery is an important goal of evaluation. When the diagnosis is in doubt and clinical judgement suggests surgery, exploration provides definite treatment as well as diagnosis, moreover the risks of negative exploration are also there.

The new techniques and diagnostic tools available are important in the management of abdominal trauma. These improved methods, however still depend on experience and clinical judgment for application and determination of best care for the injured patient.

This study is based on the blunt abdominal injury cases admitted in our hospital and it includes the assessment of aetiological aspects, age and sex distribution, modes of presentation, diagnostic modalities and management of the cases. 6.2 Review of Literature

1. Gupta S et al in their study on 63 cases of blunt abdominal trauma concluded that blunt abdominal trauma is more common in male in age group 21-30 yrs and majority were due to automobile accidents and common presentation was pain abdomen and vomiting. Abdominal paracentesis revealed haemoperitoneum in 40 cases which was subsequently confirmed on lapratomy in all the cases. Exploratory laparatomy was carried out in 43 cases, remaining were treated conservatively. They concluded that a multipronged approach towards early diagnosis and management should be adopted to reduce the morbidity and mortality in patients with blunt abdominal trauma.1 2. Michetti CP et al, in their study on 1663 patients concluded that physical examination should be used liberally for adult blunt trauma patients regardless of physical exam findings, to avoid missing clinically significant injuries. 2 3. Berg RJ et al, in their study on 1661 cases concluded that majority of solid oran injuries were managed non operatively. Overall incidence of intraabdominal solid organ injury was 59.7% and hollow viscus 6%.the abdomen contains the overwhelming majority of injuries requiring operative intervention and should be initial cavity of exploration in patients without radiologic data.3 4. Kendall JL et al in their retrosprctive study on 1169 cases concluded that most blunt abdominal trauma patients who have initially negative emergency department evaluation are at low risk for intraabdominal injuries but still require some combination of CT and conservative treatment..4 5. In 1940, Gray Turner gave valuable advise to those undertaking laparotomy for closed abdominal as follows: “The patient will not die from a very big incision, but may very likely succumb if some important injury is overlooked5. 6. Faruque AV et al in their retrospective study on 174 cases on march 2013 suggested that Focussed Abdominal Sonography for Trauma is a fairly reliable mode to assess blunt abdominal trauma in children. It is a useful tool to pick high grade solid and hollow viscus injury. The results suggest that the role of CT can be limited to those in which Focussed sonography is positive. 6 7. Millo NZ, Plewes C, Rowe BH, in their study concluded that the clinical yield of performing CT of the chest, abdomen and pelvis in motarized blunt trauma patients with normal clinical examinations was minimal.7

8. Ara R et al, in their retrospective study of 50 cases found that Ultrasound examination detected 52% of patients with intraperitoneal collection, Liver is the mostly affected organ, vulnerable age group was 11 -30 yrs, younger people more vulnerable to liver and pancreatic injury, older to splenic and middle to renal injury and Ultrasound is a primary tool to detect intraperitoneal collection .8

9. Oyo-Ita A et al, in a study on 51 participants which was at moderate risk for bias studied that there is no evidence to support the use of surgery over observation for people with abdominal trauma..9

10. Kumar S et al, in april 2012, in a retrospective study on 55 patients studied that although amylase and lipase levels in the serum and urine are not cost-effective clinical tools for routine diagnosis os extrapancreatic abdominal injuries in blunt abdominal trauma, but when coupled with other laboratory tests such as liver enzymes, they may be significant in predicting specific intra-abdominal injury.10

6.3 Objectives of the study 1. To evaluate the impact of blunt abdominal trauma on hollow viscus and solid viscera. 2. To evaluate the incidence and clinical presentation of intra-abdominal injuries. 3. To evaluate various available investigations for detecting intra-abdominal injuries. 4. To evaluate the managemen (a)non- operative (b)operative 5. To evaluate the organs affected in blunt abdominal trauma and management of different organ injuries on laparotomy. 6. To evaluate the complications, morbidity and mortality following blunt abdominal injury.

7. Materials and Methods 7.1 Source of Data;

The study will be done on patients presenting with blunt abdominal injury at the

casualty of Basaveshwar Teaching and General Hospital attached to Mahadevappa

Rampure Medical College, Gulbarga.

This study consists of 60 patients from December 2013 to September 2015.

INCLUSION CRITERIA: 1. Road traffic accidents. 2. Patients with history of recent assault by blunt and heavy object over the abdomen. 3. Patients with a history of fall from height. 4. Patients on whom there is a clinical suspicion of trauma to abdomen. 5. Patients with history of hematuria, distension of abdomen, without any specific etiology.

EXCLUSION CRITERIA :

Patients with penetrating injuries like stabbing and gun shot injuries are excluded from the study.

7.2 Methods of collection of data

The study will be conducted on a minimum of 60 patients admitted to the trauma

wards of Basaveshwar Teaching and General hospital attached to Mahadevappa

Rampure Medical college, Gulbarga. But there is scope for increasing the number of

cases depending on the availability of patients within the study period.

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals’ if so describe briefly? 1.X-ray – erect abdomen

2.X-ray – chest

3.Four quadrant aspiration.

4.Diagnostic peritoneal lavage(DPL)

5.FAST

6.Ultrasound of Abdomen

7.CT scan – abdomen

8.Intravenous Pyelography

7.4 Has Ethical clearance been obtained from your institution in case of 7.3? Yes, ethical clearance has been taken from our institution for this study.

8 List of References 1. Gupta S, Talwar S, Sharma RK, Gupta P, Goyal A, Prasad P, Department of

General Surgery, J.L.N. Medical College & Hospital, Ajmer, ‘Blunt trauma

abdomen: a study of 63 cases’ , Indian J Med Sci. 1996 Aug;50(8):272-6.

2. Michetti CP, Sakran JV, Grabowski JG, Thompson EV, Bennett K, Fakhry SM,

Inova Fairfax Hospital, Inova Regional Trauma Center, Falls Church, Virginia

22042, USA, ‘Physical examination is a poor screening test for abdominal-pelvic

injury in adult blunt trauma patients’ , J Surg Res. 2010 Mar;159(1):456-61. doi:

10.1016/j.jss.2009.04.046. Epub 2009 Jun 6.

3. Berg RJ, Okoye O, Teixeira PG, Inaba K, Demetriades D, Division of Trauma

Surgery and Surgical Critical Care, Los Angeles County University of Southern

California Medical Center, Los Angeles, CA 90033, USA, ‘The double jeopardy

of blunt thoracoabdominal trauma’ , Arch Surg. 2012 Jun;147(6):498-504. doi:

10.1001/archsurg.2011.2289.

4. Kendall JL, Kestler AM, Whitaker KT, Adkisson MM, Haukoos JS, Denver

Health Medical Center, Department of Emergency Medicine, Denver, Colorado,

‘Blunt abdominal trauma patients are at very low risk for intra-abdominal injury

after emergency department observation’, West J Emerg Med. 2011

Nov;12(4):496-504. doi: 10.5811/westjem.2010.11.2016.

5. Turner Gray (174): Abdominal injuries British Journal of Surgery 51, 767.

6. Faruque AV, Qazi SH, Khan MA, Akhtar W, Majeed A, Section of Paediatric

Surgery, Department of Surgery, The Aga Khan University Hospital, Karachi,

‘Focused abdominal sonography for trauma (FAST) in blunt paediatric abdominal

trauma’, J Pak Med Assoc. 2013 Mar;63(3):361-4.

7. Millo NZ, Plewes C, Rowe BH, Low G, Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada , ‘Appropriateness of CT of

the chest, abdomen, and pelvis in motorized blunt force trauma patients without

signs of significant injury’ ,AJR Am J Roentgenol. 2011 Dec;197(6):1393-8.

doi: 10.2214/AJR.11.6536.

8. Ara R, Khan N, Chakraborty RK, Rima SZ, Nahar N, Islam SM, Mahmud S,

Hossain GA, Islam S, Uddin F, Centre for Nuclear Medicine and Ultrasound

(CNM&U), Mymensingh, Bangladesh, ‘Ultrasound evaluation of traumatic

patient in a tertiary level hospital’ , Mymensingh Med J. 2013 Apr;22(2):255-60.

9. Oyo-Ita A, Ugare UG, Ikpeme IA, Department of Community Health, University

of Calabar Teaching Hospital, Calabar, Nigeria , ‘Surgical versus non-surgical

management of abdominal injury’ , Cochrane Database Syst Rev. 2012 Nov

14;11:CD007383. doi: 10.1002/14651858.CD007383.pub2.

10. Kumar S, Sagar S, Subramanian A, Albert V, Pandey RM, Kapoor N, Department

of Surgery, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India,

‘Evaluation of amylase and lipase levels in blunt trauma abdomen patients’ J

Emerg Trauma Shock. 2012 Apr;5(2):135-42. doi: 10.4103/0974-2700.96482. , 9 Signature of candidate

Blunt abdominal trauma is very common in this 10 Remarks of Guide region. This study is done to evaluate the cause, organs involved, diagnostic modalities and management.

11 11.1 Name and Designation of Dr.R.B.DHADED Guide. [In block letters]. MS(General Surgery) Professor Department of Surgery M.R Medical College, Gulbarga

11.2 Signature of Guide

11.3 Co-Guide -

11.4 Signature of Co-Guide -

Dr.MALLIKARJUN V. NISTY 11.5 Head of the Department MS(General Surgery) Professor and Head Department of Surgery M. R Medical College, Gulbarga, Karnataka.

11.6 Signature

12 12.1 Remarks of the Chairman and Principal.

12.2 Signature