Transcript FAST

Management
of Blunt and Penetrating
Abdominal Trauma
in Children
Department of pediatric surgery
Kharkov State Medical University
Motivation
• Trauma is the leading cause of death in the
pediatric population, and injuries to the
abdomen are the third leading cause of
pediatric trauma death, after injuries to the
head and thorax.
• The abdomen is the most common site of
unrecognized fatal injury in pediatric
trauma.
Errors are still present:
• Children often cannot adequately communicate
their injuries to physicians
• They are better able to compensate for
significant injuries, which makes vital signs less
helpful in identifying injuries early. Children
can lose up to 45% of their total blood volume
before showing any changes in blood pressure
Mechanisms for Intra-abdominal
Trauma
1.
2.
3.
4.
5.
6.
Motor vehicle collisions, pedestrian
strucks (50 %)
Falls (up to 45 % in developed countries)
Bumps, assaults
Handlebar injury from bicycle
Sports injuries
Non-accidental trauma (child abuse 5%)
The Waddell triad of injuries to head,
torso, and lower extremity
The mechanism
for the
development of
intestinal and
vertebral injuries
from lap belts
Children are predisposed because:
• They are not small adults.
• have much more pliable skeletal systems, which
helps reduce their risk of fracture but in turn
results in decreased protection of internal organs.
• The bladder has not yet settled into the pelvis.
• Children have less fat and muscle to protect them.
Along with the loose attachments of the intestines,
these put them at higher risk for deceleration
injuries.
• Children have a much smaller surface area over
which to distribute the force of impact.
1.In the hemodynamically unstable patient
with a distended abdomen, immediate
operative intervention is indicated after
completion of the primary and secondary
surveys.
2.In less critically ill patients, further
diagnostic evaluation for an intraabdominal injury is indicated.
• Primary survey:
 Quick, initial patient assessment to
identify life-threatening injuries
 Occurs with active resuscitation
• Secondary survey:
 More detailed assessment of injuries
Primary Survey
• A,B,C,D,E
• Every trauma patient should arrive
boarded and C-spine immobilized
 Collar for school-age/adolescents
 Rolls and tape for infants/toddlers
• Immediate vitals signs
A,B,C,D,Es
A = Airway & C-Spine precausions
B = Breathing (H/PTX)
C = Circulation
D = Disability
E = Exposure
F = Foley catheter unless contraindicated
G = Gastric tube unless contraindicated
A: Airway & C-Spine Protection
 Check for airway patency and clear
secretions, blood, foreign bodies, loose teeth
 Open: jaw thrust/spinal stabilization
 Clear: suction/remove particulate matter
 Support: oropharyngeal/nasopharyngeal airway
 Establish: orotracheal/nasotracheal intubation*
 Maintain: primary/secondary confirmation
 Bypass: needle/surgical cricothyroidotomy
 Ensure adequate C-spine protection
Indications for intubation
An airway unsecured because of coma, combativeness,
shock, or direct airway burns / trauma requires
endotracheal intubation.
1. Airway or breathing compromise (present or predicted)
2. Unprotected airway
3. GCS < 9
4. Combative
5. Uncooperative patients requiring CT, aortography etc.
B: Breathing
 Check for adequacy of breathing
 Effort, breath sounds, oxygenation
 Apply oxygen by facemask or blowby
 Consider need for intubation
 If already intubated confirm ETT position with:
 Chest x-ray if available
 End tidal CO2 or pedi-cap if available
 Oxygen saturation if available
 Auscultate the lungs for equal air entry
 Take a look with a laryngoscope
Breathing/Chest Wall
• Ventilation: chest rise/air entry/effort/rate
• Oxygenation: central color/pulse oximetry
• Support: respiratory distress—NRB
mask/respiratory failure — BVM ventilation
• Chest wall: ensure integrity/expand lungs
• Tension pneumothorax: needle decompression,
chest tube*
• Open pneumothorax: occlusive dressing, chest tube
• Massive hemothorax: volume resuscitation, chest
tube
Do not wait for confirmatory chest radiograph!
NRB, non-rebreather mask; BVM, bag valve mask.
C: Circulation
 Most common cause of shock in pediatrics =
hypovolemia
 TBV of child = 80ml/kg
 2 large bore IV’s started
 Xmatch or Type and screen ordered
 20 ml/kg IV crystalloid bolus (x 3 then
PRBC’s)
 Look for obvious and non-obvious sources of
bleeding
Circulation/External Bleeding
• Stop bleeding: direct pressure, avoid clamps; consider
arterial tourniquets, topical hemostats
• Shock evaluation: pulse, skin CRT, LOC
• Blood pressure: avoid over/undercorrection
Infant/child: low normal, 70 + (age x 2) mm Hg
Adolescent: low normal, 90 mm Hg
• Volume resuscitation: Ringer’s lactate (RL), then
packed cells
Infant/child: 20 mL/kg RL, repeat x 1-2 with 10
mL/PRBCs
Adolescent: 1-2 L, repeat x 1-2 with 1-2 units PRBCs
D: Disability
• Pupils reactive? Equal?
• GCS (modified) or Verbal Score
• Spontaneously moving?
• Obvious deformities?
Pediatric Verbal Score
Verbal Response
V-Score
Appropriate words/coos
Smiles, fixes/follows
Cries but consoles
5
Persistently irritable
3
Restless, agitated
2
None
1
4
From American College of Surgeons’ Committee on Trauma. Advanced Trauma Life Support for Doctors
(ATLS) Student Manual. 7th ed. Chicago: American College of Surgeons; 2004.
Glasgow Coma Scale (GCS)
Eye Opening
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal Response (Peds)
Appropriate 5
Cries, consoles 4
Persistently irritable 3
Restless, agitated 2
None 1
Motor Response
Obeys Commands 6
Localizes pain 5
Withdraws to pain 4
Flexion with pain 3
Extension to pain 2
None 1
E: Exposure
 Assess all surface areas (SBS!)
 Log-roll with using spinal precautions
 Examine the spine: note step deformities or
pain
 Assess rectal tone and sensation
 Check for vaginal/urethral bleeding
 Prevent hypothermia
 Keep trauma room warm, use blankets and
overhead warmer for infants
IDENTIFY
INTERVENE
Airway
Primary
Survey
Goals
Inadequate airway
Secure and protect
Breathing
Apnea
Positive pressure ventilation
Hypoxia
Supplemental oxygen
Tension pneumothorax
Needle decompression, chest tube
Massive hemothorax
Chest tube
Open pneumothorax
Occlusive dressing, chest tube
Circulation
Hypovolemic shock
Fluid bolus, blood products
Pericardial tamponade
Fluid bolus, pericardiocentesis, thoracotomy
Cardiac Arrest
Chest compressions, thoracotomy if penetrating trauma
Disability
Spinal cord injury
Immobilization
Cerebral herniation
Hyperventilation, mannitol
Exposure
Secondary Survey
•
•
•
•
Head to toe examination
Tetanus status
IV antibiotics if necessary
AMPLE history: allergies,
medications, past medical history,
last meal, events surrounding injury
Vascular Access - The IO Needle
If unable to secure access in 90 seconds = IO
Provides immediate vascular access when
needed
Safe to administer fluids, drugs, blood
products
Can be left for up to 72h
Use until more secure vascular access
IO: Procedure
•
•
•
•
•
•
•
•
14 to 20 gauge IO needle with stylus
Prepare area in sterile fashion and use local anesthetic
Landmarks: proximal medial aspect of tibial plateau, 12cm distal to tuberosity (aiming away from growth
plate); distal femur, 1-2cm proximal to superior border
of patella
Insert needle at 900 angle to bony surface
Avoid putting hand behind limb where IO inserted
Slowly twist after puncturing the skin until ‘release’ felt
Connect to IV tubing
Secure to skin with tape and gauze
IO Insertion
http://emedicine.medscape.com/article/940993-overview
Tools Available For Abdominal
Trauma
Physical exam
X-Rays
Ultrasound (FAST)
DPL
Computerized Tomography (CT)
Magnetic Resonance Imaging (MRI)
Diagnostic Laparoscopy
Exploratory laparotomy
•
The Abdomen is More Than Just
Abdomen:
the Abdomen
 Intraperitoneal cavity
• Clinical exam
• FAST
• DPL
• CT scan
• Exploratory laparoscopy
• Exploratory laparotomy
 Retroperitoneal cavity &
pelvis
• Pelvic xray
• CT scan
• Exploratory laparotomy
• Thorax
(thoracoabdominal
injuries)
 CXR
• Heart & Great Vessels
(cardiac box injuries)
 Cardiac FAST
 CXR
• Diaphragm & Bladder
(innocent bystanders)
 Diagnostic laparoscopy
 CT cystogram
What Are We Worried About?
• Bleeding:
 Spleen
 Liver
 Kidneys
 Mesentery
• Bowel:
 Contamination (rupture), haematoma, mesentery
• Bladder:
 Intraperitoneal rupture
• Diaphragm:
 Mainly on the left side
Frequency of Pediatric Blunt
Abdominal Injuries
• Spleen 37%
• Kidney 27%
• Liver 18%
• Pancreas 2%
Abdominal bruisisng
Physical Examination
• Neither sensitive nor specific to rule
out intra-peritoneal hemorrhage
(Kulenkampff’s, Weinert’s,
Rozanov’s “tilting doll” sign)
• Excellent to watch for the
development of peritonitis
(contamination)
Physical Examination
• Generally unreliable due to distracting injury,
spinal cord injury
• Look for signs of intraperitoneal injury
 abdominal tenderness, peritoneal irritation,





gastrointestinal hemorrhage, hypovolemia, hypotension
entrance and exit wounds to determine path of injury.
Distention - pneumoperitoneum, gastric dilation, or ileus
Ecchymosis of flanks (Gray-Turner sign) or umbilicus
(Cullen's sign) - retroperitoneal hemorrhage
Abdominal contusions – eg lap belts and bruises
↓bowel sounds suggests intraperitoneal injuries
Rosen’s Emergency Medicine, 7th ed. 2009
X-RAY
Patients with suspected intra-abdominal injuries should
undergo radiographic evaluation of the lateral cervical spine,
chest, and pelvis. Although these studies are unlikely
to
verify an intra-abdominal injury, they may reveal
important other injuries.
The chest radiograph may demonstrate massive gastric
distention and the position of the nasogastric tube.
Rarely free intraperitoneal
and missiles can be elicited.
air, foreign bodies
Initial chest
radiograph of an
injured child
demonstrating
massive gaseous
distention of the
stomach.
Other imaging
Angiography
 To embolize bleeding vessels or solid visceral
hemorrhage from blunt trauma in an
unstable patient
 Rarely used for diagnosing intraperitoneal
and retroperitoneal hemorrhage after
penetrating abdominal trauma
FAST
The FAST (focused assessment with sonography in
trauma) exam is an option in the initial evaluation of
trauma patients, when a quick decision must be made
(either to initiate immediate celiotomy or to continue
resuscitation and evaluation for extra-abdominal
hemorrhage or severe brain or spinal injury. ).
This quick bedside study evaluating for the presence of
free fluid in:
• perihepatic & hepato-renal recess [Morison pouch],
• splenorenal space,
• pelvis (Pouch of Douglas/rectovesical pouch),
• pericardial space (subxiphoid)
FAST
FAST - Morrison’s pouch (hepato-renal space)
Note presence of an
anechoic stripe
representing a fluid
collection between the
liver and kidney (solid
arrow).
FAST - Retrovesicle (Pouch of Douglas)
Positive fluid in the sagittal retrovesicle view
(arrow). Note anechoic stripe indicative of
retroperitoneal fluid.
FAST
• Advantages:
 Portable, fast (<5 min),
 No radiation or contrast
 Less expensive
• Disadvantages
 Not as good for solid parenchymal damage,
retroperitoneum, or diaphragmatic defects.
 Limited by obesity, substantial bowel gas, and subcut air.
 Can’t distinguish blood from ascites.
 high (31%) false-negative rate in detecting
hemoperitoneum in the presence of pelvic fracture
Diagnostic Peritoneal Lavage
(DPL)
• Described in 1965, standard of care
• Open, semi-open or closed (Seldinger) approach
• Highly accurate for hemoperitoneum (Sn = 95%, Sp = 99%)
 Lead to a non-therapeutic laparotomy rate of 36%
• Laparotomy when:
 10 cc gross blood
 Enteric contents
 1 L warmed NS: > 100 000 RBC / mm3 or > 500 WBC / mm3
• High false positives with pelvic fractures
 Do a supraumbilical approach
• High Sn for hollow viscus injuries
 Moreso than CT
• Risk of visceral injury = 0.6%
• Retroperitoneum can’t be assessed
Diagnostic Peritoneal Lavage
In real life:
1. Good tool if FAST
equivocal in the HD
abnormal pt. in the setting
of a pelvic fracture
2. FAST unavailable, pt. is
HD abnormal
Diagnostic Peritoneal Lavage
• Largely replaced by FAST and CT
• In blunt trauma, used to triage pts who is HD
unstable and has multiple injuries with an
equivocal FAST examination
• In stab wounds, for immediate determination of
hemoperitoneum, intraperitoneal organ injury,
and detection of isolated diaphragm injury
• In GSW, not used much
Computerized Tomography
• Imaging modality of choice only in HD normal patients
 Pts crumping in CT a performance indicator in trauma
centres
• Sn = 92-97%, Sp = 99% for bleeding
 Active arterial contrast extravasation, blush or
pseudoaneyrysm
• Only modality to directly detect retroperitoneal injury
• Poor test to diagnose diaphragmatic injury
• Less accurate for HVI
 Still need serial physical exams
 If pelvic fluid is present in absence of solid organ injury –
exploratory laparotomy is mandated, especially if moderate
or large amounts of free fluid
Computerized Tomography
1. CT is recommended for the evaluation of
hemodynamically stable patients with equivocal
findings on physical examination, associated
neurologic injury, or multiple extra-abdominal injuries.
Under these circumstances, patients with a negative CT
should be admitted for observation
2. CT is the diagnostic modality of choice for nonoperative management of solid visceral injuries (i.e.
bleeding). If HD stable with a positive FAST, follow up CT
permits nonoperative management of select injuries
3.In HD stable patients, DPL and CT are complementary
diagnostic modalities
Computerized Tomography
By minimizing the incidence of
non-therapeutic laparotomies for selflimited injury to the liver or spleen,
trauma centers are using CT with
intravenous (IV) contrast only.
Non-operative management of
solid organ injury is now more
common
ATLS - advanced trauma life support
PALS - pediatric advanced life
support
Initial Management of the Bleeding Patient – European
Guidelines; 2007
• Recommendation 1:
 That time elapsed between injury and operation be minimized
for pts. In need of urgent surgical control
• Recommendation 2:
 That a grading system be used to assess the clinical extent of
hemorrhage
• Recommendation 3:
 pts. presenting in hemorrhagic shock AND an identified source
of bleeding undergo an immediate bleeding control procedure
UNLESS initial resuscitation measures are successful
• Recommendation 4:
 pts. with an unidentified source of bleeding in hemorrhagic
shock should undergo immediate further assessment
• Recommendation 5:
 Trauma pts. should be resuscitated initially with crystalloid to
a BP of 80-100 mmHg in the absence of TBI
Initial Management of the Bleeding Patient – European
Guidelines; 2007
• Recommendation 6:
 Early FAST for the detection of FF in patients with
suspected torso trauma
• Recommendation 7:
 Pts. with significant FF on FAST with hemodynamic
instability should undergo urgent surgery
• Recommendation 8:
 HD normal pts. with suspected head, chest and/or
abdominal bleeding following high-energy injuries
should undergo further assessment using CT
• Recommendation 9:
 Single Hct is not helpful; lactate or base deficit is
helpful to estimate and monitor the extent of bleeding
and shock
Fluid Administration in Pediatric Abdominal Trauma
Initial Resuscitation
• Identify what is
bleeding:“4 & on the floor”
1.
Chest
1. CXR
2.
3.
Intraperitoneal abdomen
• Very little to do in the
trauma bay prior to OR
if HD abnormal:
 Intubate
1. FAST
 CXR
Retroperitoneal abdomen
 Group & screen
1. PXR, CT scan
4.
Extremities – (femur #s)
1. XRs
• Then stop it:
 OR
 Angioembolization
 Tourniquet
• If crashing:
 Bilateral chest tubes
• If dying:
 ED thoracotomy
 Reduction & stabilization
• Get to OR ASAP
Patient in Extremis = ED Thoracotomy
Indications for Laparotomy –
Blunt Abdominal Trauma
Absolute Indications:
1. Shock (HD unstable patients with a
positive FAST)
2. Frank Peritonitis (HVI)
3. Blood out of NG tube or on rectal exam
4. Intraperitoneal bladder rupture
5. Diaphragmatic rupture
6. Positive DPL
Indications for Early Operation in Abdominal Trauma in
Childhood
Blunt
Hemodynamic instability despite adequate volume resuscitation
Transfusion requirement >50% of estimated blood volume
Physical signs of peritonitis
Endoscopic evidence of rectal tear
Radiologic evidence of intraperitoneal or retroperitoneal gas
Radiologic evidence of gastrointestinal perforation
Radiologic evidence of renovascular pedicle injury
Radiologic evidence of pancreatic transection
Bile, bacteria, stool, or >500 WBC/mm3 on peritoneal lavage
Penetrating
All gunshot wounds
All stab wounds associated with evisceration; blood in stomach, urine,
or rectum; physical signs of shock or peritonitis; radiologic evidence of
intraperitoneal or retroperitoneal gas
All suspected thoracoabdominal injuries (unless excluded by
thoracoscopy or laparoscopy)
Bile, bacteria, stool, or >500 WBC/mm3 on peritoneal lavage
ATTENTION!
• In stable – go to the OR for a laparotomy
 If you are worried about contamination (HVI)
• Fluid in the pelvis in absence of SOI
 If you are worried about an intraperitoneal
bladder injury or large diaphragmatic injury
• In unstable – go to the OR for a laparotomy
 If the bleeding is in the abdominal cavity
 If the bleeding is in the pelvis for packing as still
ongoing after stabilizing
Open Book Pelvic Fracture
Pelvic Fracture has large potential
space for hemorrhage
Initial Management of the Bleeding Patient – European
Guidelines; 2007
• Recommendation 10:
 Pts. in shock with pelvic ring fractures should undergo
immediate closure and stabilization
• Recommendation 11:
 If ongoing instability, proceed to early angioembolization or
surgical bleeding control such as packing
• Recommendation 12:
 Early bleeding control must be achieved by packing, direct
surgical bleeding control, the use of local hemostatic
procedures. If pt. is exsanguinating, aortic cross-clamping
may be employed as an adjunct
• Recommendation 13:
 Damage control surgery should be employed in the severely
injured pt. with signs of shock, ongoing bleeding and
coagulopathy
Management of Pelvic Trauma
Surgical consult
Pelvic wrap
Intraperitoneal gross blood?
Yes
No
Laparotomy
Angiography
Control hemorrhage
Fixation device
Col (ret) Mark W. Bowyer MD
Close Pelvis – Many Devices
Available to Close Pelvic Ring
The Lethal Triad of Death
Damage Control Resuscitation
• Damage Control Conception - patients
with major exsanguinating injuries may
not survive complex procedures
• Control hemorrhage and contamination
with abbreviated laparotomy followed by
resuscitation prior to definitive repair
Damage Control Resuscitation
• Permissive hypotension
• 1:1:1 resuscitation (pRBCs, platelets, FFP)
• Damage control surgery
 Stop the bleeding (pack)
 Control the contamination
 Definitive surgical anatomical restoration later
Damage Control Resuscitation
0. Initial resuscitation
1. Control of hemorrhage and contamination
Control injured vasculature, bleeding solid organs
Abdominal packing
2. Back to the ICU for resuscitation
Correction of hypothermia, acidosis, coagulopathy
3. Definitive repair of injuries
4. Definitive closure of the abdomen
Specific visceral injuries
Splenic Trauma
• Diagnosis:
• Plain abdominal film
• Unreliable and
nonspecific
• Triad of radiographic
findings in acute splenic
rupture
• Left diaphragmatic
elevation
• Left lower lobe
atelectasis
• Left pleural effusion
Radiograph demonstrates a left pleural
effusion, left basilar atelectasis, and
inferomedial displacement of the splenic
flexure (arrow)
Splenic Trauma
• Diagnosis:
• FAST
• Focused Assessment with
Sonography in Trauma
• Bedside study for unstable
patient
• 15% false-negative
• May miss up to 25% of liver
and spleen injuries
• Compared to CT only 63%
sensitive for detecting free
fluid
Fluid in the subphrenic space and
splenorenal recess can be detected.
The image shown demonstrates blood
(arrow) between the spleen (S) and
diaphragm (D).
•
Focused Assessment With
Sonography
in
Trauma
(FAST)
Looks for free intra-abdominal fluid (assumed to be blood
or gastrointestinal content, may be other)
 Also pericardial fluid
• Non-invasive, no radiation, repeatable
• Highly Sn (79-100%) and Sp (96-100%)
 Moreso in hemodynamic pts. after BAT
 Repeating FAST also increases Sn
• May still need other imaging modalities when negative
• Can be performed with equal accuracy by surgeons
• Use controversial in penetrating trauma of the abdomen
 Only helpful if positive
 VERY helpful for detecting intrapericardial blood
FAST
Advantages
Flaws
Repeatability
It does little to evaluate
or stage organ injuries
and rarely dictates the
management
Non-invasiveness
Highly sensitivity in the
detection of free fluid
Performer-dependent
Splenic Trauma
• Diagnosis:
• CT with IV contrast
• Noninvasive, highly
accurate, easily
identifies and
quantifies extent of
injury, for stable
patient only
A: Hemoperitoneum with a liver
laceration (arrow) and a
shattered spleen is seen.
AAST Splenic Injury Scale
USED TO GUIDE THE TREATMENT PROTOCOLS BUT NOT
AS AN INDICATION FOR SURGICAL INTERVENTION
AAST Splenic Injury Scale
17-yo boy injured due to an assault. Grade I injury with
subcapsular fluid occupying less than 10% of spleen’s
surface area.
AAST Splenic Injury Scale
17-yo girl injured in an MVC. Grade II injury with
laceration involving less than 3 cm of parenchymal
depth
AAST Splenic Injury Scale
18-yo boy injured playing football. Lacerations
involving more than 3 cm of parenchymal depth
radiating from splenic hilum -grade III laceration
AAST Splenic Injury Scale
16-yo boy injured playing hockey. Fractured
spleen involving more than 25%, Grade IV
splenic laceration
AAST Splenic Injury Scale
12-yo boy pedestrian struck by MV.
Fractured spleen with hilar
devascularization. Grade V injury.
Splenic Trauma
• Complications
• Pseudoaneurysms
• Often asymptomatic
and resolve over
time
• If treatment
required,
angiographic
embolization may
be used
• Also occur in liver
trauma
A. Splenic pseudoaneurysm
(arrowheads) after nonoperative
treatment of blunt splenic injury.
B. Successful angiographic
embolization The microcatheter
used to deploy the coils is marked
by the arrowheads and the embolic
coils are marked by the arrows.
Splenic Trauma
• Complications
• Pseudocysts
• Rare: 0.44%
• May become large
and painful
• Tx: laparoscopic
excision and
marsupialization
Splenic Trauma
• If splenectomy is indicated
• Pt requires vaccinations prior to discharge
• Streptococcus pneumoniae
• Pneumovax 23
• Haemophilus influenzae type B
• Hib vaccine
• Neisseria meningitidis
• Quadravalent meningococcal/diphtheria
conjugate
• Prophylactic antibiotics controversial
• Most centers use penicillin
Splenic Trauma
• Treatment
• Nonoperative failure rate 2%
• Risks for increased nonoperative
failure rate
• Bicycle-related injury mechanism
• More than one solid organ injury
• Peaks at 4 hrs, declines at 36hrs
after admission
Contrast Blush - Spleen
• Contrast blush on CT scan implies:
• Lower HgB
• More likely to need operation (22% vs 4%)
• Not a definite indication for operation, but
indicates subset of patients who have active
bleeding and may need transfusion and/or
operation
Spleen injury Operative management
Treatment is aimed at splenic preservation, with or
without surgery
1. Full mobilization of the spleen with
delivery into the operative field is necessary
for adequate assessment.
2. Stop the haemorrhage – by pressure, coagulation
of bleeding sites, topical haemostatic agents (Fibrin
Glue), splenorraphy with deep investing sutures,
suture ligation of individual vessels, partial
splenectomy incorporating the segmental arterial
blood supply and aiming to maintain at least
30-50% of the splenic tissue.
Splenectomy
1. Exsanguinating haemorrhage, usually
associated with a hilar or pedicle injury
2. The operation is likely to be prolonged by
attempting a splenorraphy in a child with
multiple injuries (not able to sustain)
Liver Trauma
• Blunt trauma is most common
cause of injury to liver
• High risk due to:
• Large organ, friable
parenchyma, ligamentous
attachments
AAST Liver Injury Grading
Liver Trauma
Free fluid in the right upper quadrant on FAST scan
Types of Injury
• Parenchymal damage/laceration
• Subcapsular hematoma/contusion
• Hepatic vascular disruption – contrast
extravasation
• Bile duct injury
Grade I
Grade IV
Diagnosis
• Physical exam –
• ±tachycardia, ±hypotention,
peritoneal irritation
• FAST –
• better for unstable patients
not stable enough for CT1
• CT with contrast
enhancement
• determine grade and look for
active extravasation
Contrast Blush - Liver
Contrast blush means:
• more transfusion required
• higher mortality (23% vs 4%)
• surgical intervention warranted
• mortality may be related to the other injuries
Indications for Intervention
• Operate for continued blood loss with hypotension,
tachycardia, decreased urine output, decreasing Hg
unresponsive to IVF and pRBC (despite blood
transfusion >40ml/kg)
• Operative rates
• 3-11% for multiple injuries
• 0-3% for isolated liver injury
• Angioembolization – not used as commonly as in
adults
Bile Duct Injury
• With nonoperative management, 4% risk of
persistent bile leak
• HIDA (hepatobiliary scintigraphy) with delayed
images if bile duct injury suspected
• ERCP (endoscopic retrograde
pancreatcholangioography) with decompression
and stenting – can be diagnostic and therapeutic
Hepatic injury operative management
• Simple suture ligation
• Application of local haemostatic agents (tissue glue,
gelfoam, sponge)
• Perihepatic packing, using dry radiopaque marked packs
to tamponade the liver between the body wall and the
diaphragmatic surface
• Hepatic vascular isolation
• Deep mattress suture hepatorraphy
• Mesh hepatorrhaphy
• Omental flap to cover the laceration
• Debridement
• lobar or segmental resections of devitalised parenchyma
• Liver transplantation
• Ligation or repair damaged vessels&bile duct
Hepatic vascular isolation
Vascular occlusion can
safely be maintained for
at least 45- min without
long-term sequelae
(Pringle, 1908 )
APSA Guidelines
APSA guidelines for hemodynamically stable children with isolated
spleen or liver injury
CT GRADE
I
II
III
IV
Days in ICU
None
None
None
1 day
Hospital stay
2 days
3 days
4 days
5 days
Predischarge
imaging
None
None
None
None
Postdischarge
imaging
None
None
None
None
3 weeks
4 weeks
5 weeks
6 weeks
Activity
restrictions
From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource
utilization in children with isolated spleen or liver injury.
J Pediatr Surg 35:164-169, 2000
Organ Injury Scale for Kidney (AAST)
grade
Injury type Description of injury
I
Contusion
Hematoma
Micro/gross hematuria, urologic studies N
Subcapsular, nonexpanding without
parenchymal laceration
II
Hematoma
Laceration
Nonexpanding perirenal hematoma confirmed to
renal retroperitoneum
˂1 cm parenchymal depth of renal cortex without
urinary extravasation
III
Laceration
˃1 cm parenchymal depth of renal cortex without
collecting system rupture or urinary extravasation
IV
Laceration
Vascular
Parenchymal L extending through renal cortex,
medulla and collecting system
Main renal artery/vein injury with contained hg
V
Laceration
Vascular
Completely shattered kidney
Avulsion of renal hilum that devascularize kidney
Renal injury
Surgery is warranted:
- major parenchymal laceration with urinary
extravasation
- >20% non-viable parenchyma
- recurrent severe haematuria after >72 h
observation
In stable patients operation/nephrectomy
should be avoided
In high Grades RENAL SALVAGE by early
vascular repair is desirable, but only 5% truly
successful revascularizations after blunt
trauma have been reported
Pancreas
1. Management is conservative in 40-80%
2. Surgery - major injury (traumatic division or
major pancreatic duct laceration), suggested by
increasing abdominal tenderness, an elevated
amylase on peritoneal aspiration and a
persistently raised or rising serum amylase level
3. Procedure - distal pancreatectomy with
external drainage
Solid Organ Injury
• Treatment
• > 90% of hemodynamically stable pts
successfully managed non-operatively
• Less than 10% require transfusion
Penetrating Abdominal Trauma
• Violation of Peritoneum
means risk of intraabdominal injury that
requires surgery
• Caused by stab wounds
• Caused by gun shot
wounds
• Caused by other
penetrating objects
Do not remove
penetrating objects!
Must remove in a
controlled setting
(Operating Room)
Management of penetrating abdominal
trauma - mandatory laparotomy vs
selective nonoperative management
Management of penetrating
abdominal trauma
• Mandatory laparotomy
 standard of care for abdominal stab wounds until
1960s, for GSWs until recently
 Now thought unnecessary in 70% of abdominal stab
wounds
 Increased complication rates, length of stay, costs
 Immediate laparotomy indicated for shock,
evisceration, and peritonitis
Management of penetrating
abdominal trauma
• Selective management used to reduce
unnecessary laparotomies
• Diagnostic studies to determine if there is
intraperitoneal injury requiring operative
repair
• Strategy depends on abdominal region:
 Thoracoabdomen
• Nipple line to costal margin
 Anterior abdomen
• Xiphoid to pubis
 Flank and back
• Posterior to anterior axillary line
Management of penetrating
abdominal trauma
Thoracoabdomen
• Big concern is diaphragmatic injury
 7% of thoracoabdominal wounds
• Diagnostic evaluation:
 CXR (hemothorax or pneumothorax)
 Diagnostic peritoneal lavage
 FAST
 Thoracoscopy
Thoracoabdomen
Management of penetrating
abdominal trauma
• Anterior abdomen
 Only 50-70% of anterior stab wounds enter the




abdomen
of these, only 50-70% cause injury requiring OR
1. is immediate lap indicated ?
2. Has peritoneal cavity been violated?
3. Is laparotomy required?
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of PAT
• Anterior abdomen
Rosen’s Emergency Medicine 7th ed
Management of penetrating
abdominal trauma
• Back/Flank
 Risk of retroperitoneal
injury
 Intraperitoneal organ
injury 15-40%
 Difficulty evaluating
retroperitoneal organs
with exam and FAST
 In stable pts, CT scan is
reliable for excluding
significant injury:
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Management of penetrating
abdominal trauma
Gunshot wounds
• Much higher mortality than stab wounds
• Over 90% of pts with peritoneal penetration
have injury requiring operative management
• Most centers proceed to lap if peritoneal entry
is suspected
• Expectant management rarely done
Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:609-617
Rosen’s Emergency Medicine 2009
Management of PAT
Gunshot wounds
• assess peritoneal
entry by missile
path, LWE, CT, US,
laparoscopy (all
limited)
Rosen’s Emergency Medicine, 7th ed. 2009
How common are injuries that
require surgical repair?
 Anterior abdominal stab wounds:
 25-33% will need a laparotomy
 Posterior or flank stab wounds:
 15% will need a laparotomy
 Anterior gun shot wounds:
 58-75% will need a laparotomy
 Posterior gun shot wounds:
 33% will need a laparotomy
Absolute Indications for
Laparotomy – Penetrating
Abdominal Trauma
1. Shock
2. Peritonitis
3. Evisceration
4. Weapon still in situ
5. Blood out of NG tube
or on rectal exam
1. Gross hematuria
Stab Wounds –
Anterior Abdominal Wall
 Not all stab wounds to the anterior
abdominal wall (AAW) will have:
 Violated the peritoneum
 Caused intraabdominal injury requiring
operative repair
 Up to 50% of stab wounds to the AAW will
not violate the peritoneum
 Up to 50% that violate the peritoneum do not
cause injury requiring operative repair
Local Wound Exploration
• To determine the depth of penetration in stab
wounds
• If peritoneum is violated, must do more diagnostics
• Prepare, extend wound, carefully examine (No
blind probing!)
• Indicated for anterior abdominal stab wounds,
less clear for other areas
Stab Wounds –
Anterior Abdominal Wall
1. Local Wound Exploration (LWE)

Sterile procedure with local anesthetic
2. Serial Physical Examinations (SPE)

Done by same clinician to assess for the
development of peritonitis
3. Focused Assessment with Sonography for
Trauma (FAST)

‘Not indicated’ in penetrating trauma
4. Diagnostic Peritoneal Lavage (DPL)

Not done in many centers
Stab Wounds –
Anterior Abdominal Wall
5. Computerized Tomography (CT)

Historically not used for AAW stab wounds
▪
More useful in penetrating injury to the flank and back
6. Diagnostic Laparoscopy

Used to rule out:
▪
▪
Peritoneal penetration
Diaphragmatic injury on left side
7. Exploratory Laparotomy

Still the gold standard in ruling out intraabdominal injury
CT Scan for Anterior Abdominal
Wall Stab Wounds
 Not well defined, evolving modality
 Does not add much to serial physical exams
 Poor test for:
 Hollow viscus injuries
 Diaphragm injuries
 Use if:
1. High suspicion of solid organ injury based on
wound location (R or LUQ)
2. Positive FAST exam
3. Hematuria
Pitfalls
1. DPL:

Cumbersome
Sensitivity poor for hollow viscus injury
Different criteria for positive tests in different centers
Positive test for RBC’s does not equate to needing a
therapeutic laparotomy



•
Many solid organ injuries managed non-operatively now
2. FAST (Soffer, 2004):


Very limited role in penetrating abdominal trauma
Rarely changes management, even if positive (1.7%)
Pitfalls
3. Diagnostic laparoscopy:

Only identifies peritoneal violation
Not sensitive for hollow viscus or retroperitoneal
injury
Automatic conversion to laparotomy will still
result in a high non-therapeutic rate
Still largely reserved to rule out diaphragmatic
injury with left thoracoabdominal SWs



•
30% will have an injury to the diaphragm
–
Caution: 10% develop a tension pneumothorax
intraoperatively if no chest tube in place
Non-Operative Management of Stab
Wounds – EAST 2010
1.
2.
3.
4.
Hemodynamically stable
No peritonitis or diffuse abdominal pain
In a center with surgical expertise
Patient is evaluable*
*Evaluable: absence of brain or spinal
cord injury, intoxication or need for
sedation or anesthesia
•
20% of patients selected for NOM will fail
(Clarke et al., 2010)
Stab Wounds Flank and Back
 Laparotomy used to be standard of care
 Fletcher, 1989
 Non-operative management with 3CT in 76% of
patients with SWs to flank & back
 Jurkovich et al, 2009
 Triple contrast CT scan has replaced DPL
 Evaluates retroperitoneum as DPL cannot
 Now mandatory laparotomy replaced with
triple contrast CT scan for stab wounds to
flank and back
Thoracoabdominal Stab Wounds
• Historically, 33% of patients with left
thoracoabdominal stab wounds with have a
diaphragmatic injury
• Patients with left thoracoabdominal stab wounds
may be observed for 12 hours
• If no need for laparotomy by that time, may
repair diaphragm using laparoscopic techniques
Cardiac Box
Mediastinum
Thoracoabdominal area
• While selective management of anterior
abdominal stab wounds is appropriate...
• Selective management of anterior abdominal
GSWs is still controversial
• But this can reduce the rate of nontherapeutic laparotomy from 30-50%
to 5-10%
Non Operative Management of Gun
Shot Wounds – Guidelines (EAST) 2010
1.Hemodynamically stable
2.Tangential wound
3.No peritoneal signs
4.Consider only if patient is evaluable
5.Exception if GSW to RUQ
Non Operative Management of Gun Shot Wounds
to Right Upper Quadrant (Non-Tangential) Guidelines
• Absolute indications:
1.
2.
3.
Hemodynamically
stable
Patient is evaluable*
Minimal to no
abdominal tenderness
* Evaluable: absence of
brain or spinal cord
injury, intoxication or
need for sedation or
anesthesia
How long to observe?
• Patients with penetrating abdominal
injuries selected for NOM should be
observed for 24 hours (recommended by
most centers)
• They may be discharged after 24 hours in
the presence of a reliable physical exam and
minimal to no tenderness
• The majority of asymptomatic patients who
failed NOM after SWs did so within 12
Laparoscopy
• Most useful to evaluate penetrating wounds to
thoracoabdominal region in stable pts
 esp for diaphragm injury: Sens 87.5%, specificity 100%
• Can repair organs via the laparoscope
 diaphragm, solid viscera, stomach, small bowel.
• Disadvantages:
 poor sensitivity for hollow visceral injury, retroperitoneum
 Complications from trocar misplacement.
 If diaphragm injury, PTX during insufflation
Summary – Stab Wounds to Abdomen
• Non-operative management if no:
 Shock, peritonitis, evisceration & patient
evaluable
• LWE as per clinician preference
 May discharge patient home if no fascial
violation
• Serial physical exams by same clinician X
24 hours
 Watch for peritonitis, discharge home if
minimal or no pain
Summary – Stab Wounds to Abdomen
• CT scan if
 SW to R or LUQ to rule out solid organ injury
 SW to flank or back as CT may rule out peritoneal
violation
• May send home after or..
 May observe patient after CT for 24 hours nonetheless
• Delayed laparoscopy after 12 hours of
observation if
 TAA SW to left upper quadrant to identify and repair
any diaphragmatic injury
Summary – GSW to Abdomen
• Non-operative management if no:
 Shock, peritonitis, evisceration & evaluable
• All patients undergo CT scanning
 Anterior abdomen, flank or back
 If GSW tangential (no peritoneal breach) & no
peritoneal signs, patient may be discharged
 If solid organ injury, may manage non-operatively
• Consider repeat imaging in 7 days to manage
asymptomatic complications in 50%
 If hollow viscus injury, proceed with laparotomy
 If no apparent injury, observe for 24 hours
Summary – Penetrating
Abdominal Trauma
• Low threshold to operate
• Don’t forget trauma to thoracic structures if
TAA
• FAST only helpful with bleeding if positive
 Always do a pericardial FAST if close to the box
• CT only helpful with bleeding
 Less so with HVI
• Serial physical exams helpful in all