Permissive hypotension, also known as hypotensive resuscitation, involves allowing trauma patients with penetrating injuries to have a lower blood pressure to avoid disrupting unstable blood clots and worsening bleeding until emergency surgery can control the hemorrhage. The goal is to maintain adequate tissue perfusion while avoiding excessive fluid resuscitation that could lead to rebleeding and complications. Damage control resuscitation aims for a minimal volume, normotensive approach with a target mean arterial pressure of 65 mmHg for penetrating trauma patients without head injuries.
2. OUTLINE
INTRODUCTION
• Trimodal distribution of death
ASSESSMENT & RESUSCITATION
• Primary and Secondary Survey
• Adjuncts of resuscitation
• Recognition of abdominal trauma
ABDOMINAL TRAUMA
• Types of abdominal Trauma
• Mechanism injury
• Specific organ Injury
TAKE HOME MESSAGES
3. INTRODUCTION
definition: an injury (such as wound) to living tissue caused by an extrinsic
agent.
-trauma is one of common reasons for death and hospitalization in Malaysia (
Journalarticleukm.com ‘epidemiology study of abdominal and pelvic injury trauma in post mortem cases at HKL 2008-2009’
4. A) Death due to massive
injuries. Seconds to
minutes.
B) Death due to hemorrhage.
Hours.
C) Death due to late
complications of trauma.
Days to weeks.
*golden hour – in the 1st hour,
30% of death takes place
• Aggressive resuscitation
during this time can
greatly improve the
chances of survival
5. Lethal triad of death in trauma
Severe haemorrhage →
hypovolemic shock →
Hypothermia +
coagulopathy
+ acidosis
3 factors aggravate each
other
in a vicious cycle → further
bleeding → intractable
shock
→ death
6. ATLS way of trauma management
Preparation
and Triage
Primary
Survey
Reevaluation
Secondary
Survey
reevaluation
Definitive
Care
Constantly reevaluating traumatic patient is crucial to ensure
that new findings are not overlooked and to discover deterioration
in previously noted findings.
8. PRIMARY SURVEY
- Focused, quick and simple way in assessment of
trauma patient.
Aim: detect for 6 life threatening conditions
1. Airway obstructions
2. Tension pneumothorax
3. Open pneumothorax
4. Massive pneumothorax
5. Flail chest
6. Cardiac tamponade
9. A: airway with cervical spine control
-look for sign of airway obstruction
-Intubation is indicated:
1. Poor GCS: <9
2. Severe maxillofacial fractures: laryngeal/tracheal
injury
3. Hypoxia
B: breathing
-Assess breath sounds, chest percussion, chest wall
excursion, and jugular venous distension.
- By clinically can exclude life threatening conditions.
10. • 3. circulation with hemorrhage control
Assess for
and stop
external
hemorrhage
Assess for
tissue
perfusion
Gain
vascular
access
Fluid
Resus-
citation
Assess for
response
•Direct manual
pressure
•tourniquet
•Vital signs
•Skin: color
temp, CRT
•Mental status
•Urine: 1cc/kg/h
•Two large
bore iv
cannula
(16 gauge)
•IV crystalloid
20mls/kg
•Penetrating trauma:
“permissive
hypotension”
principles
11.
12. D: Disability (neurological evaluation)
• Level of consciousness: Glasgow Coma Scale
• Pupil symmetry and reaction to light
• Lateralizing signs and spinal cord injury level
E: Exposure/environmental
– Remove all clothing to facilitate access and
examination.
– Logroll maneuver to examine patient’s back.
– Maintain normothermia.
17. Focused Assessment with
Sonography in Trauma (FAST)
• To diagnose free intraperitoneal fluid
• Sensitivity 86- 99% - the larger the freefluid the higher the
sensitivity
Pericardium
(subxiphoid
perisplenic
Perihepatic&
hepato-renal
space(morrison’
s pouch)
Pelvis (Pouch of
Douglas/
rectovesical pouch)
18. CT SCAN
• Accurate for solid visceral lesions and its grading and
intraperitoneal hemorrhage.
• Sensitivity for solid organ is 95%, diaphragmatic 60% and
pancreatic 30%
• Reveal associated injuries.
• Indications: FAST +ve and only hemodynamically stable
patient
• Contraindications: clear indication for exp laparotory, unstable
patient.
19. Indication of Laparotomy
1. Hypotension with penetrating abdominal
wound
2. Evisceration
3. Bleeding of abdomen from penetrating trauma
4. Free air, retroperitoneal air or rupture
hemidiaphragm
20. Diagnostic peritoneal lavage(DPL)
Is a surgical diagnostic procedure to determine if there is
free fluid (most often blood) in the abdominal cavity.
• Criteria for +VE DPL:
1. Receive 10ml of gross blood
2. Cell count:
• RBC >100,000
• WBC > 500
3. Biochemistry: Amylase >175iu/ml
4. Microscopic : food particle,bile, bacteria
• no longer use nowadays due to presence of FAST scan
and CT scan.
24. •Cullen’s sign
•-bluish discoloration around umbilicus
•-diffusion of blood along periumbilical tissues of falciform
ligament
•-hemoperitoneum/severe pancreatitis
•Grey Turner’s sign
•-bluish discoloration of the flanks
•-retroperitoneal hematoma/hemorrhagic pancretatiis
•Kehr's sign is the occurrence of acute pain in the tip of the
shoulder due to the presence of blood or other irritants in
the peritoneal cavity when a person is lying down and the
legs are elevated.
• classic symptom of a ruptured spleen.
•Seatbelt syndrome is defined as a seatbelt sign associated
with a lumbar spine fracture and a bowel perforation
25. • Lower rib fracture are associated with spleen
and liver injury.
26. MECHANISM OF INJURY
Blunt trauma Penetrating injury
Direct blow Stab wound
Shearing/ deceleration injuries Gunshot wound
27. ABDOMINAL TRAUMA
Abdominal Truma
Blunt Abdominal
Trauma (BAT)
Solid Organ
Hollow Organ
Penetrating
Abdominal Trauma
(PAT)
Gunshot/Evisceration
Stab Trauma
28. Definition
Blunt abdominal trauma refers to when abdominal
organs are compressed against the backbone, or
when internal structures are stretched at their
attachments.
Penetrating abdominal trauma typically results in
direct injury to organs in the direct path of the
instrument or missile.
Source : The NHS UK
35. Splenic injury
• Most commonly injured organ in blunt abdominal trauma
• May occur after minor trauma in diseased spleen
• Splenic injury is graded depending on the extent and depth
of splenic haematoma and/or laceration identified on CT
scan
• Low grade splenic injuries are suitable for non-operative
management, although more recent evidence suggests that
higher grades may also be suitable with the adjunct of
angioembolisation
• To be considered if:
— a contrast blush is seen on CT
— AAST grade > III
— moderate hemoperitoneum is present
— evidence of ongoing bleeding
36. Splenic injury
CONSERVATIVE
MANAGEMENT
▫ Hemodynamic stable
▫ Absence of contrast
extravasation in CT
▫ Subcapsular Hematoma
<50%, Laceration <3cm
▫ Evidence of
pseudoaneurysm
• Serial abdominal
examination and CT scan.
• Close monitoring in HDU
OPERATIVE MANAGEMENT
• Total Splenectomy
• Vaccination
*Predictive of failure in
conservative if :
- Active contrast extravasation
- Evidence of pseudoaneurysm
on CT scan
37. Subcapsular
hematoma <10%,
Capsular tear <1cm
Subcapsular
hematoma 10-15% or
intraparenchymal
<5cm diameter,
Capsular tear 1-3cm
(not involving vessel)
Subcapsular hematoma
>50%, ruptured, or
parenchymal hematoma.
Laceration >3cm involving
trabecular vessel
Laceration of
segmental or hilar
vessels producing
major
devascularization
Completely shattered
spleen + hilar vascular
injury
38. Liver injury
•Largest organ - 85% with blunt hepatic
trauma are stable
•CT with contrast – main stay of diagnosis in
stable patient
39. Liver Injury
CONSERVATIVE
MANAGEMENT
• Haemodynamically stable
• No other intra abdominal
injury require surgery
• Close monitoring of patient
Failed conservative if
- Peritonitis
- Hypotension
- Evisceration
- Proctorrhagia
- Hematoma
OPERATIVE MANAGEMENT
• Liver packing (via
tamponade effect)
• Pringle’s maneuver – direct
compression to portal triad
via Foramen of Winslow
• Lobar Resection
• Liver Transplantation
40.
41. Renal injury
• Clinically not suspected & frequently overlooked
• Most genitourinary injuries are not immediately life-threatening
• Renal pedicle injury can lead to life-threatening hemorrhage and renal ischemia
• Clinical - Shock, hematuria & pain over the loin
• Urine : gross or microscopic
• CT scan – Grading
• Indications for nephrectomy
• Hemodynamic instability
• Grade 5 renal injury / renovascular injury
• Extensive contrast extravasation
• Expanding / pulsatile retroperitoneal hematoma
42.
43. Zone 1 ; midline
retroperitoneum, from
aortic hiatus to sacral
promontory. The
supramesocolic area and
inframesocolic area
Zone 2 ; kidneys,
paracolic gutter and renal
vessels
Zone 3 ; pelvic
retroperitoneum and iliac
vessels
Vascular injury
44.
45.
46. Hollow Organ injury
• Gastric, Gallbladder, Small or Large Bowel, Urinary Bladder,
Ureter
• Perforations with spillage of content into peritoneal cavity or
retroperitoneal space
• Sign and symptoms of peritonitis
• Treatment : simple suture closure or rapid resection of
involved segment, no anastomosis are performed
• Complications :
• Sepsis
• Wound infection
• Abscess formation
47. Damage Control Surgery
•Patients of blunt or penetrating abdominal trauma
with hemodynamic instability are generally better
served with abbreviated operations that helps in
prevention from the lethal triad of death.
48. Damage
Control
Surgery
Phases of DCS
Initial operation with
hemostasis and packing (OT)
Stabilization of physiological
status in ICU
Definitive Surgery (OT)
Things to
monitor
Physiological Parameters
Haematological Parameters
49. TAKE HOME MESSAGE
1. The correct sequence of priorities for assessment of a
multiply injured patient is preparation- triage-primary
survey and resuscitation- secondary survey-reevaluation-
and definitive care.
2. Permissive hypotension is for patients without brain
injury.
3. FAST scan has 86-99% in diagnosing intraperitoneal fluid.
4. Special sign’s in recognising abdominal trauma( Cullen
sign, kehr sign, grey turner sign, seatbelt syndrome)
5. Indication laparotomy: blunt trauma with hypotension
and FAST +ve, penetrating trauma, peritonitis, free air,
retroperitoneal air or rupture of hemidiaphragm.
50. 5. Liver and spleen injury most common in blunt trauma
6. Solid organ injury in haemodynamically stable patients
can often be managed without surgery
7.Grade I through III hepatic injuries can be managed in a
non-monitored setting. Grades IV and V should be
admitted to the ICU for close monitoring, serial physical
exams and blood counts.
8.Damage control surgery involved controlling
hemorrhage allowing subsequent focus on resuscitation,
correction of coagulopathy and avoiding hypothermia.
51. References
• ATLS for Doctors, 9th edition
• Journalarticle.ukm.com.my
• Bailey & Love Short Practice of Surgery, 25th edition
• http://www.surgeons.org.uk/advanced-trauma-life-
support/shock.html
• Clinical companion in surgery
53. PERMISSIVE HYPOTENSION
OVERVIEW
• Permissive hypotension is also known as hypotensive resuscitation and low volume
resuscitation
• The concept remains controversial and is primarily applicable to the penetrating
trauma patient.
• It is considered part of damage control resuscitation, along with haemostatic
resuscitation and damage control surgery.
APPROACH
• Allow SBP to fall low enough to avoid exsanguination but keep high enough to
maintain perfusion
• Goal is to avoid disruption of an unstable clot by higher pressures and worsening of
bleeding (“don’t pop the clot”)
• Avoids cyclic over-resuscitation that can lead to rebleeding and paradoxically
exacerbate hypotension despite increased fluid resuscitation and subsequent
complications
• Low BP is not the target, it is a compromise pending emergency surgical
intervention
• Haemorrhage control is the goal, once this achieved (e.g. haemostasis and surgery)
normalisation of haemodynamics is appropriate
54. • A MINIMAL VOLUME NORMOTENSIVE APPROACH
• Target = MAP of 65 mmHg (assuming patient is adequately perfused at this
blood pressure and there is not a coexistant head injury demanding a
higher BP target)
— targets above this risk “popping the clot”, fluid overload and dilutional
coagulopathy
• If MAP < 65 – give fluids/ blood products
• If MAP > 65 – check perfusion (strong pulse, warm peripheries)
-> MAP > 65 with good perfusion -> perform masterful inactivity
-> MAP > 65 with poor perfusion -> give fentanyl 20-25 mcg (decreases
catacholamine release resulting in vasodilation, if MAP drops <65 mmHg
then give fluids/ blood products as above)
Useful for predicting the likelihood f success with nonoperative management (higher for low grade injury – I, II, III)
Grade IV and above: universally haemodynamically unstable.
control hemorrhage allowing subsequent focus on resuscitation, correction of coagulopathy and avoiding hypothermia.
