Abdominal truma 2007

1. Presented by :Presented by :
Dr. Rashid AbuelhassanDr. Rashid Abuelhassan
ABDOMINAL TRUMAABDOMINAL TRUMA

2.  Blunt Abdominal traumaBlunt Abdominal trauma
 DPLDPL
 Penetrating abdominal traumaPenetrating abdominal trauma
 Diagnostic ProceduresDiagnostic Procedures
 Intra abdominal injuriesIntra abdominal injuries
– Diaphragm injuriesDiaphragm injuries
– Liver traumaLiver trauma
– Kidneys traumaKidneys trauma
– Pancreas traumaPancreas trauma
– Stomach traumaStomach trauma
– DuodenalDuodenal
– Small bowelSmall bowel
– ColonColon
– Splenic ruptureSplenic rupture
____________________________________
Refrences:Refrences:
1- www.webMD.com
2-2- www.eMedicine.com
Tutorial outlineTutorial outline

3. 1) Blunt Abdominal Truma1) Blunt Abdominal Truma
IntroductionIntroduction
 CausesCauses
 motor vehicle collisionsmotor vehicle collisions
 AssaultsAssaults
 recreational accidentsrecreational accidents
 falls.falls.
 The most commonly injured organs areThe most commonly injured organs are
spleen, liver, retroperitoneum, small bowel, kidneys,spleen, liver, retroperitoneum, small bowel, kidneys,
bladder, colorectum, diaphragm, and pancreas.bladder, colorectum, diaphragm, and pancreas.

4. statisticsstatistics
 In 2005, approximately 5 million people diedIn 2005, approximately 5 million people died
worldwide as a result of injury .worldwide as a result of injury .
 Globally, injury accounts for 10% of all deaths;Globally, injury accounts for 10% of all deaths;
however, injuries in sub-Saharan Africa are far morehowever, injuries in sub-Saharan Africa are far more
destructive than in other areas .destructive than in other areas .
 Estimates indicate that by 2020, 8.4 million peopleEstimates indicate that by 2020, 8.4 million people
will die yearly from injury, and injuries from trafficwill die yearly from injury, and injuries from traffic
collisions will be the third most common cause ofcollisions will be the third most common cause of
disability worldwide and the second most commondisability worldwide and the second most common
cause in the developing world.cause in the developing world.
1) Blunt abdominal truma1) Blunt abdominal truma

5. pathophysiologypathophysiology
Blunt force injuries to the abdomen canBlunt force injuries to the abdomen can
generally be explained by 3 mechanisms:generally be explained by 3 mechanisms:
1.1. rapid deceleration causes differentialrapid deceleration causes differential
movement among adjacent structuresmovement among adjacent structures
2.2. crushed between the anterior abdominal wallcrushed between the anterior abdominal wall
and the vertebral column or posterior thoracicand the vertebral column or posterior thoracic
cagecage
3.3. rise in intra-abdominal pressure and culminaterise in intra-abdominal pressure and culminate
in rupture of a hollow viscous organin rupture of a hollow viscous organ
1) Blunt abdominal truma1) Blunt abdominal truma

6. Advanced Trauma Life Support protocolAdvanced Trauma Life Support protocol
AAirway, with cervical spine precautionsirway, with cervical spine precautions
BBreathingreathing
CCirculationirculation
DDisabilityisability
EExposurexposure
1) Blunt abdominal truma1) Blunt abdominal truma
Clinical ActClinical Act

7. Clinical ActClinical Act
 History:History: (should be quick while doing ABCs)(should be quick while doing ABCs)
– The extent of vehicular damageThe extent of vehicular damage
– Whether prolonged extrication was requiredWhether prolonged extrication was required
– Whether the passenger space was intrudedWhether the passenger space was intruded
– Whether a passenger diedWhether a passenger died
– Whether the person was ejected from theWhether the person was ejected from the
vehiclevehicle
– The role of safety devices such as seat beltsThe role of safety devices such as seat belts
and airbagsand airbags
– The presence of alcohol or drug useThe presence of alcohol or drug use
– The presence of a head or spinal cord injuryThe presence of a head or spinal cord injury
– Whether psychiatric problems were evidentWhether psychiatric problems were evident
1) Blunt abdominal truma1) Blunt abdominal truma

8.  Points to rememberPoints to remember
– AllergiesAllergies
– MedicationsMedications
– Past medical and surgical historyPast medical and surgical history
– Time of last mealTime of last meal
– Immunization statusImmunization status
– Events leading to the incidentEvents leading to the incident
– Social history, including history of substanceSocial history, including history of substance
abuseabuse
– Information from family and friendsInformation from family and friends
– patient should be examined repeatedly andpatient should be examined repeatedly and
at frequent intervalsat frequent intervals
1) Blunt abdominal truma1) Blunt abdominal truma

9. Symptoms and signsSymptoms and signs
Ask AboutAsk About
 PainPain
 TendernessTenderness
 gastrointestinal hemorrhagegastrointestinal hemorrhage
 HypovolemiaHypovolemia
 evidence of peritoneal irritationevidence of peritoneal irritation
The abdomen is examened forThe abdomen is examened for
 abrasions or ecchymosisabrasions or ecchymosis
 The seat belt signThe seat belt sign
 abdominal distentionabdominal distention
 Grey Turner signGrey Turner sign
 Cullen signCullen sign
 Auscultation of bowelAuscultation of bowel
 PalpationPalpation
 A rectal examinationA rectal examination
1) Blunt abdominal truma1) Blunt abdominal truma

10. Points to Be in MindPoints to Be in Mind
 DPL is indicated in blunt trauma as follows:DPL is indicated in blunt trauma as follows:
 Patients with a spinal cord injuryPatients with a spinal cord injury
 Those with multiple injuries and unexplained shockThose with multiple injuries and unexplained shock
 Obtunded patients with a possible abdominal injuryObtunded patients with a possible abdominal injury
 Intoxicated patients in whom abdominal injury is suggestedIntoxicated patients in whom abdominal injury is suggested
 Patients with potential intra-abdominal injury who will undergoPatients with potential intra-abdominal injury who will undergo
prolonged anesthesia for another procedureprolonged anesthesia for another procedure
 immediate blood transfusion is indicated in hemodynamicimmediate blood transfusion is indicated in hemodynamic
instability despite the administration of 2 L of fluid to adultinstability despite the administration of 2 L of fluid to adult
patients; this instability indicates ongoing blood loss.patients; this instability indicates ongoing blood loss.
 Indications for laparotomy in a patient with blunt abdominalIndications for laparotomy in a patient with blunt abdominal
injury include the following:injury include the following:
 Signs of peritonitisSigns of peritonitis
 Uncontrolled shock or hemorrhageUncontrolled shock or hemorrhage
 Clinical deterioration during observationClinical deterioration during observation
 Hemoperitoneum findings after FAST or DPL examinationsHemoperitoneum findings after FAST or DPL examinations
1) Blunt abdominal truma1) Blunt abdominal truma

11. 
The onlyThe only AbsoluteAbsolute contraindicationcontraindication
to DPL is the obvious need forto DPL is the obvious need for
laparotomy.laparotomy.
RelativeRelative contraindications includecontraindications include
morbid obesity, a history of multiplemorbid obesity, a history of multiple
abdominal surgeries, and pregnancy.abdominal surgeries, and pregnancy.
1) Blunt abdominal truma1) Blunt abdominal truma

12. About DPLAbout DPL
DPL is considered positiveDPL is considered positive
 in a blunt trauma patient with 10 mL ofin a blunt trauma patient with 10 mL of
grossly bloody aspirate obtained beforegrossly bloody aspirate obtained before
infusion of the lavage fluid orinfusion of the lavage fluid or
if the siphoned lavage fluid (ie, 1 Lif the siphoned lavage fluid (ie, 1 L
normal saline infused into the peritonealnormal saline infused into the peritoneal
cavity via a catheter and allowed to mix,cavity via a catheter and allowed to mix,
which is then drained by gravity) haswhich is then drained by gravity) has
more than 100,000 RBC/mL, more thanmore than 100,000 RBC/mL, more than
500 WBC/mL, elevated amylase content,500 WBC/mL, elevated amylase content,
bile, bacteria, vegetable matter, or urinebile, bacteria, vegetable matter, or urine
Only approximately 30 mL of blood isOnly approximately 30 mL of blood is
needed in the peritoneum to produce aneeded in the peritoneum to produce a
microscopically positive DPL resultmicroscopically positive DPL result
1) Blunt abdominal truma1) Blunt abdominal truma

13. Methods of DPLMethods of DPL
1. Open
2. Semiopen
3. closed methods
1) Blunt abdominal truma1) Blunt abdominal truma

14. Lab Workup
 CBC & coagulation studies, blood type, and bloodCBC & coagulation studies, blood type, and blood
cross-matchcross-match
 Urine studies include urinalysis, urine toxicologicUrine studies include urinalysis, urine toxicologic
screen, and serum or urine pregnancy tests inscreen, and serum or urine pregnancy tests in
females of appropriate age.females of appropriate age.
 Serum electrolyte values, creatinine level, andSerum electrolyte values, creatinine level, and
glucose values are often obtained for referenceglucose values are often obtained for reference
 The serum lipase or amylase level is neitherThe serum lipase or amylase level is neither
sensitive nor specific as a marker for majorsensitive nor specific as a marker for major
pancreatic or enteric injurypancreatic or enteric injury
 All patients should have their tetanusAll patients should have their tetanus
immunization history reviewed. If it is notimmunization history reviewed. If it is not
current, prophylaxis should be given.current, prophylaxis should be given.
1) Blunt abdominal truma1) Blunt abdominal truma

15. Imaging StudiesImaging Studies
 Plain radiographPlain radiograph
 UltrasoundUltrasound
(70 mL of blood could be detected, while 30 mL(70 mL of blood could be detected, while 30 mL
is the minimum requirement for detection withis the minimum requirement for detection with
ultrasound )ultrasound )
 Computed tomographyComputed tomography
 LaparoscopyLaparoscopy
1) Blunt abdominal truma1) Blunt abdominal truma

16. TreatmentTreatment
 ABCsABCs
 Nonoperative management
– strategies on CT scan diagnosis and the hemodynamic
stability of the patient are now being used in the
treatment of adult solid organ injury
– Angiography is a valuable modality in theAngiography is a valuable modality in the
nonoperative management of adult abdominalnonoperative management of adult abdominal
solid organ injuries from blunt traumasolid organ injuries from blunt trauma
1) Blunt abdominal truma1) Blunt abdominal truma

17. Surgical TreatmentSurgical Treatment
• When laparotomy is indicated, broad-
spectrum antibiotics are given
• After intraperitoneal injuries are
controlled, the retroperitoneum and pelvis
must be inspected.
• Do not explore pelvic hematomas
• observation, and hemoperitoneum findings
after FAST or DPL examinations
• After the source of bleeding has been
stopped, further stabilizing the patient
with fluid resuscitation and appropriate
warming is important
1) Blunt abdominal truma1) Blunt abdominal truma

18. complicationcomplication
 Complications associated with BATComplications associated with BAT
includes but are not limited to theincludes but are not limited to the
following:following:
– Missed injuriesMissed injuries
– Delays in diagnosisDelays in diagnosis
– Delays in treatmentDelays in treatment
– Iatrogenic injuriesIatrogenic injuries
– Intra-abdominal sepsis and abscessIntra-abdominal sepsis and abscess
– Inadequate resuscitationInadequate resuscitation
– Delayed splenic ruptureDelayed splenic rupture
1) Blunt abdominal truma1) Blunt abdominal truma

19. 2) Penetrating abdominal truma2) Penetrating abdominal truma
IntroductionIntroduction
Penetrating abdominal
injury implies that
either:
•A GSW
•A stab wound has
violated the abdominal
cavity.

20. PathophysiologyPathophysiology
 GSW is caused by a missile propelled byGSW is caused by a missile propelled by
combustion of powder.combustion of powder.
– These wounds involve high-energy transfer and,These wounds involve high-energy transfer and,
consequently, can have an unpredictable pattern ofconsequently, can have an unpredictable pattern of
injuries.injuries.
– Secondary missiles, such as bullet and bone fragments,Secondary missiles, such as bullet and bone fragments,
can inflict additional damage.can inflict additional damage.
– Military and hunting firearms have higher missileMilitary and hunting firearms have higher missile
velocity than handguns, resulting in even higher energyvelocity than handguns, resulting in even higher energy
transfertransfer
– Close-range shotgun injuries often cause significantClose-range shotgun injuries often cause significant
tissue damage and should be considered high-energytissue damage and should be considered high-energy
transfer injuries as welltransfer injuries as well
2) Penetrating abdominal truma2) Penetrating abdominal truma

21. PathoPathophysiologyphysiology ofof GSWGSW
 GSWs are associated with a highGSWs are associated with a high
incidence of intra-abdominal injuries.incidence of intra-abdominal injuries.
Nearly all patients with GSWs requireNearly all patients with GSWs require
laparotomylaparotomy
 Patients without recordable cardiacPatients without recordable cardiac
activity upon presentation should notactivity upon presentation should not
be further resuscitated.be further resuscitated.
2) Penetrating abdominal truma2) Penetrating abdominal truma

22. Stab woundStab wound
 Stab wounds are caused by penetration ofStab wounds are caused by penetration of
the abdominal wall by a sharp object. Thisthe abdominal wall by a sharp object. This
type of wound generally has a moretype of wound generally has a more
predictable pattern of organ injury.predictable pattern of organ injury.
However, occult injuries can beHowever, occult injuries can be
overlooked, resulting in devastatingoverlooked, resulting in devastating
complications.complications.
 associated with a significantly lowerassociated with a significantly lower
incidence of intra-abdominal injuries;incidence of intra-abdominal injuries;
therefore, expectant management istherefore, expectant management is
indicated in hemodynamically stableindicated in hemodynamically stable
patientspatients
2) Penetrating abdominal truma2) Penetrating abdominal trumaPathoPathophysiologyphysiology ofof Stab woundsStab wounds

23. Clinical AssesmentClinical Assesment
 Assessment of the patient begins at the scene of theAssessment of the patient begins at the scene of the
incident by emergency medical service (EMS) personnelincident by emergency medical service (EMS) personnel
1.1. Physical examination includes inspection of all bodyPhysical examination includes inspection of all body
surfaces, with notation of all penetrating wounds.surfaces, with notation of all penetrating wounds.
Multiple wounds may represent entrance or exit woundsMultiple wounds may represent entrance or exit wounds
and must not be labeled as such, since multiple missilesand must not be labeled as such, since multiple missiles
or foreign objects may be retained within the bodyor foreign objects may be retained within the body
2.2. signs, such as pain and guarding andsigns, such as pain and guarding and
rebound tenderness, which necessitate explorationrebound tenderness, which necessitate exploration
without delaywithout delay
2) Penetrating abdominal truma2) Penetrating abdominal truma

24. 3. Abdominal distension in an unresponsive patient may3. Abdominal distension in an unresponsive patient may
indicate active internal bleeding that also requiresindicate active internal bleeding that also requires
exploration, especially in combination with hypotension.exploration, especially in combination with hypotension.
4. Rectal examination is performed on all patients with PAT,4. Rectal examination is performed on all patients with PAT,
as blood per rectum and high-riding prostate can indicateas blood per rectum and high-riding prostate can indicate
bowel injury and genitourinary tract injury, respectively.bowel injury and genitourinary tract injury, respectively.
Notation of blood at the urethral meatus is also a sign ofNotation of blood at the urethral meatus is also a sign of
genitourinary tract injury.genitourinary tract injury.
5. When immediate operative intervention is not requisite,5. When immediate operative intervention is not requisite,
further evaluation ensues with laboratory testing andfurther evaluation ensues with laboratory testing and
diagnostic and imaging studiesdiagnostic and imaging studies
2) Penetrating abdominal truma2) Penetrating abdominal truma

25. Diagnostic ProceduresDiagnostic Procedures
 Nasogastric intubationNasogastric intubation
 Blood in the nasogastric tube can indicate upperBlood in the nasogastric tube can indicate upper
gastrointestinal injurygastrointestinal injury
 Foley catheterizationFoley catheterization
 Blood in the nasogastric tube can indicate upperBlood in the nasogastric tube can indicate upper
gastrointestinal injurygastrointestinal injury
 Diagnostic peritoneal lavageDiagnostic peritoneal lavage
 closed methodclosed method
 open methodopen method
 Semi open methodSemi open method
 Tube thoracostomyTube thoracostomy
 Rigid sigmoidoscopyRigid sigmoidoscopy
2) Penetrating abdominal truma2) Penetrating abdominal truma

26. Initial treatmentInitial treatment
 At least 2 large-bore peripheralAt least 2 large-bore peripheral
intravenous catheters should be securedintravenous catheters should be secured
 Fluids should be administered rapidlyFluids should be administered rapidly
 Arterial access for continuous bloodArterial access for continuous blood
pressure monitoring is standardpressure monitoring is standard
 warm blankets and prewarmed fluids.warm blankets and prewarmed fluids.
Antibiotics should be administered toAntibiotics should be administered to
patients undergoing explorationpatients undergoing exploration
2) Penetrating abdominal truma2) Penetrating abdominal truma

27. Preoperative detailsPreoperative details
 The patient is placed in the supineThe patient is placed in the supine
position with arms extendedposition with arms extended
 The entire chest, abdomen, andThe entire chest, abdomen, and
pelvis, including the upper thighs,pelvis, including the upper thighs,
are prepped and drapedare prepped and draped
 Entering the abdominal cavity canEntering the abdominal cavity can
release tamponade, resulting in arelease tamponade, resulting in a
precipitous drop in blood pressure,precipitous drop in blood pressure,
2) Penetrating abdominal truma2) Penetrating abdominal truma

28. Intra operativelyIntra operatively
Goals :Goals :
1.1. control of bleedingcontrol of bleeding
2.2. identification of injuriesidentification of injuries
3.3. control of contaminationcontrol of contamination
4.4. reconstruction (if possible).reconstruction (if possible).
2) Penetrating abdominal truma2) Penetrating abdominal truma

29. Diphragm InjuriesDiphragm Injuries
Classifiction :Classifiction :
(I) Contusion(I) Contusion
(II) laceration, <2 cm(II) laceration, <2 cm
(III) laceration, 2-10 cm(III) laceration, 2-10 cm
(IV) laceration, >10 cm(IV) laceration, >10 cm
(V) total tissue loss, >25 cm2(V) total tissue loss, >25 cm2
2) Penetrating abdominal truma2) Penetrating abdominal truma

30. LiverLiver InjuriesInjuries
 (I) nonbleeding capsular tears, <1 cm(I) nonbleeding capsular tears, <1 cm
deepdeep
 (II) lacerations, 1-3 cm deep and <10 cm(II) lacerations, 1-3 cm deep and <10 cm
longlong
 (III) laceration, >3 cm deep(III) laceration, >3 cm deep
 (IV) parenchymal disruption involving 25-(IV) parenchymal disruption involving 25-
75% of a lobe or 1-3 segments75% of a lobe or 1-3 segments
 (V) parenchymal disruption of >75% of a(V) parenchymal disruption of >75% of a
lobe or >3 segments or juxtahepaticlobe or >3 segments or juxtahepatic
venous injuryvenous injury
 (VI) hepatic avulsion.(VI) hepatic avulsion.
2) Penetrating abdominal truma2) Penetrating abdominal truma

31.  Operative management of liver injuries can involve manyOperative management of liver injuries can involve many
techniquestechniques
– including simple packing or wrappingincluding simple packing or wrapping
– local hemostasislocal hemostasis
– resectional debridementresectional debridement
Packing may successfully control minor hemorrhage; however, packsPacking may successfully control minor hemorrhage; however, packs
may need to be left in place and the abdomen closed temporarily.may need to be left in place and the abdomen closed temporarily.
 Several hemostatic agents have been used in liver repair:Several hemostatic agents have been used in liver repair:
– including thrombin fibrin sealantincluding thrombin fibrin sealant
– collagen/gel preparationscollagen/gel preparations
– electrocauteryelectrocautery
– argon beamargon beam
– radiofrequency coagulationradiofrequency coagulation
– omental packingomental packing
– even intrahepatic balloon tamponade as in the case of through-and-even intrahepatic balloon tamponade as in the case of through-and-
through injuriesthrough injuries
– Resectional debridement is much less commonly required in theResectional debridement is much less commonly required in the
treatment of penetrating liver injuries but may be accomplished withtreatment of penetrating liver injuries but may be accomplished with
finger fracture, cautery, sutures, clips, or stapler device.finger fracture, cautery, sutures, clips, or stapler device.
2) Penetrating abdominal truma2) Penetrating abdominal truma

33. KidneyKidney InjuriesInjuries
 (I) contusion; (II) lacerations, <1(I) contusion; (II) lacerations, <1
cm; (III) lacerations, >1 cm; (IV)cm; (III) lacerations, >1 cm; (IV)
lacerations to the collecting system;lacerations to the collecting system;
and (V) vascular avulsion.and (V) vascular avulsion.
2) Penetrating abdominal truma2) Penetrating abdominal truma

34. PancreasPancreas
 Grades I and II include superficial orGrades I and II include superficial or
major laceration or contusion withoutmajor laceration or contusion without
ductal injury, respectively. Grade IIIductal injury, respectively. Grade III
injuries are distal transections withoutinjuries are distal transections without
duct injury or tissue loss. Grade IVduct injury or tissue loss. Grade IV
lacerations involve proximal transection orlacerations involve proximal transection or
parenchymal injury involving the ampulla.parenchymal injury involving the ampulla.
Grade V injuries are massive disruptions ofGrade V injuries are massive disruptions of
the pancreatic head.the pancreatic head.
2) Penetrating abdominal truma2) Penetrating abdominal truma

35. StomachStomach InjuriesInjuries
 opening of the gastrocolic ligament,opening of the gastrocolic ligament,
which allows entrance into the lesserwhich allows entrance into the lesser
sac. Injuries extending into thesac. Injuries extending into the
lumen may be repaired quickly withlumen may be repaired quickly with
a stapling device.a stapling device.
2) Penetrating abdominal truma2) Penetrating abdominal truma

36. DuodenumDuodenum
 (I) hematoma; (II) partial thickness(I) hematoma; (II) partial thickness
laceration; (III) laceration disruptinglaceration; (III) laceration disrupting
<50% circumference of D1, D3, D4, or<50% circumference of D1, D3, D4, or
50-75% circumference of D2; (IV)50-75% circumference of D2; (IV)
laceration disrupting 50-100%laceration disrupting 50-100%
circumference of D1, D3, D4, or >75%circumference of D1, D3, D4, or >75%
circumference of D2, or involving thecircumference of D2, or involving the
ampulla or distal common bile duct; andampulla or distal common bile duct; and
(V) massive disruption of the(V) massive disruption of the
duodenopancreatic complex orduodenopancreatic complex or
devascularization of the duodenum.devascularization of the duodenum.
2) Penetrating abdominal truma2) Penetrating abdominal truma

38. Small bowelSmall bowel
 Control of contamination is of highControl of contamination is of high
priority with penetrating injuries topriority with penetrating injuries to
the small bowel. Clamps or staplesthe small bowel. Clamps or staples
may be used for temporary controlmay be used for temporary control
as the entire length of the smallas the entire length of the small
bowel is examined.bowel is examined.
2) Penetrating abdominal truma2) Penetrating abdominal truma

39. ColonColon
 The management of colonic injuriesThe management of colonic injuries
depends on the extent of the defect,depends on the extent of the defect,
the amount of contamination, andthe amount of contamination, and
the stability of the patient. Primarythe stability of the patient. Primary
repair may be considered if therepair may be considered if the
patient is hemodynamically stablepatient is hemodynamically stable
and if the injury is fairly small withand if the injury is fairly small with
minimal fecal contaminationminimal fecal contamination
2) Penetrating abdominal truma2) Penetrating abdominal truma

40.  Early postoperative complications includeEarly postoperative complications include
ongoing bleeding, coagulopathy, andongoing bleeding, coagulopathy, and
abdominal compartment syndrome. Theabdominal compartment syndrome. The
latter is treated with opening of thelatter is treated with opening of the
abdomen and temporary closure.abdomen and temporary closure.
 Later complications include acuteLater complications include acute
respiratory distress syndrome, pneumonia,respiratory distress syndrome, pneumonia,
sepsis, intra-abdominal fluid collections,sepsis, intra-abdominal fluid collections,
wound infections, and enterocutaneouswound infections, and enterocutaneous
fistulae.fistulae.
 Late complications include small bowelLate complications include small bowel
obstruction and incisional hernias.obstruction and incisional hernias.
2) Penetrating abdominal truma2) Penetrating abdominal truma

41. Spleen InjuriesSpleen Injuries
 The spleen, weighing 75-150 g, is a highlyThe spleen, weighing 75-150 g, is a highly
vascular organ that filters an estimatedvascular organ that filters an estimated
10-15% of total blood volume every10-15% of total blood volume every
minute. The spleen may hold 40-50 mL ofminute. The spleen may hold 40-50 mL of
red cells in reserve on average; however,red cells in reserve on average; however,
with changes in internal smooth muscle, itwith changes in internal smooth muscle, it
can pool significantly more bloodcan pool significantly more blood
 EtiologyEtiology
 penetrating traumapenetrating trauma
 blunt traumablunt trauma
 explosive type injuriesexplosive type injuries
2) Penetrating abdominal truma2) Penetrating abdominal truma

42. pathophysiologypathophysiology
 Though normally protected by its anatomicThough normally protected by its anatomic
position, preexisting illness or disease canposition, preexisting illness or disease can
markedly increase the risks and severity ofmarkedly increase the risks and severity of
splenic injury. Infectious mononucleosis, malaria,splenic injury. Infectious mononucleosis, malaria,
and hematologic abnormalities can lead to acuteand hematologic abnormalities can lead to acute
or chronic enlargement of the spleen. This isor chronic enlargement of the spleen. This is
often accompanied by a thinning of the capsule,often accompanied by a thinning of the capsule,
making the spleen more fragile as well asmaking the spleen more fragile as well as
engendering a greater mass effect in deceleratingengendering a greater mass effect in decelerating
trauma. Minor impact in patients withtrauma. Minor impact in patients with
splenomegaly reportedly results in major injurysplenomegaly reportedly results in major injury
and the need for splenectomyand the need for splenectomy
2) Penetrating abdominal truma2) Penetrating abdominal truma

43. Clinical featuresClinical features
 The clinical presentation of splenic injury is highlyThe clinical presentation of splenic injury is highly
variable. Most patients with minor focal injury tovariable. Most patients with minor focal injury to
the spleen complain of right upper quadrantthe spleen complain of right upper quadrant
abdominal tenderness. Left shoulder tendernessabdominal tenderness. Left shoulder tenderness
may also be present as a result ofmay also be present as a result of
subdiaphragmatic nerve root irritation withsubdiaphragmatic nerve root irritation with
referred pain.referred pain.
 With free intraperitoneal blood, diffuse abdominalWith free intraperitoneal blood, diffuse abdominal
pain, peritoneal irritation, and reboundpain, peritoneal irritation, and rebound
tenderness are more likely. If the intra-abdominaltenderness are more likely. If the intra-abdominal
bleeding exceeds 5-10% of blood volume, clinicalbleeding exceeds 5-10% of blood volume, clinical
signs of early shock may manifestsigns of early shock may manifest
2) Penetrating abdominal truma2) Penetrating abdominal truma

44.  Signs include tachycardia, tachypnea,Signs include tachycardia, tachypnea,
restlessness, and anxiety. Patients may have arestlessness, and anxiety. Patients may have a
mild pallor noted only by friends and family.mild pallor noted only by friends and family.
Clinical signs include decreased capillary refill andClinical signs include decreased capillary refill and
decreased pulse pressure. With increasing blooddecreased pulse pressure. With increasing blood
loss into the abdominal cavity, abdominalloss into the abdominal cavity, abdominal
distension, peritoneal signs, and overt shock maydistension, peritoneal signs, and overt shock may
be observed.be observed.
 Hypotension in a patient with a suspected splenicHypotension in a patient with a suspected splenic
injury, especially if young and previously healthy,injury, especially if young and previously healthy,
is a grave sign and a surgical emergency.is a grave sign and a surgical emergency.
2) Penetrating abdominal truma2) Penetrating abdominal truma

45. Indications of surgical interventionIndications of surgical intervention
 In simple terms, unstable patients suspected ofIn simple terms, unstable patients suspected of
splenic injury and intra-abdominal hemorrhagesplenic injury and intra-abdominal hemorrhage
should undergo exploratory laparotomy andshould undergo exploratory laparotomy and
splenic repair or removal. A blunt trauma patientsplenic repair or removal. A blunt trauma patient
with evidence of hemodynamic instabilitywith evidence of hemodynamic instability
unresponsive to fluid challenge with no otherunresponsive to fluid challenge with no other
signs of external hemorrhage should besigns of external hemorrhage should be
considered to have a life-threatening solid organconsidered to have a life-threatening solid organ
(splenic) injury until proven otherwise. Transient(splenic) injury until proven otherwise. Transient
responders, those patients who respond to anresponders, those patients who respond to an
initial fluid bolus only to deteriorate again with ainitial fluid bolus only to deteriorate again with a
drop in blood pressure and increasingdrop in blood pressure and increasing
tachycardia, are also likely to have solid organtachycardia, are also likely to have solid organ
injury with ongoing hemorrhageinjury with ongoing hemorrhage
2) Penetrating abdominal truma2) Penetrating abdominal truma

46.  In the stable trauma patient,In the stable trauma patient,
commonly defined as a patient withcommonly defined as a patient with
systolic blood pressure greater thansystolic blood pressure greater than
90 mm Hg with a heart rate less90 mm Hg with a heart rate less
than 120 beats per minute (bpm),than 120 beats per minute (bpm),
CT scanning provides the most idealCT scanning provides the most ideal
noninvasive means for evaluating thenoninvasive means for evaluating the
spleen.spleen.
2) Penetrating abdominal truma2) Penetrating abdominal truma

47. Imaging studyImaging study
 RadiographyRadiography
– Chest radiograph is obtained on all because
penetration of the chest cavity cannot be ruled
out, even with abdominal stab wounds or
even-numbered GSWs patients
– Abdominal radiographs in 2 views (ie, AP,
lateral) are also obtained on all patients with
GSWs to help determine missile trajectory and
to account for retained missiles in patients with
odd-numbered GSWs.
– The focused assessment with sonography for
trauma (FAST) uses 4 views of the chest and
the abdomen
2) Penetrating abdominal truma2) Penetrating abdominal truma

48.  CT scan is used in the evaluation ofCT scan is used in the evaluation of
patients with stab wounds to the flank andpatients with stab wounds to the flank and
the back and in the evaluation of selectedthe back and in the evaluation of selected
patients with abdominal stab wounds andpatients with abdominal stab wounds and
GSWsGSWs
 Intravenous Pylogram is more often usedIntravenous Pylogram is more often used
intraoperatively to assess contralateralintraoperatively to assess contralateral
renal function in a patient with kidneyrenal function in a patient with kidney
damage necessitating nephrectomydamage necessitating nephrectomy
2) Penetrating abdominal truma2) Penetrating abdominal truma

49. Diagnostic procedureDiagnostic procedure
 Diagnostic peritoneal lavageDiagnostic peritoneal lavage
– DPL is a method of rapidly determining if freeDPL is a method of rapidly determining if free
intraperitoneal blood is present. This test isintraperitoneal blood is present. This test is
especially useful in the hypotensive patient.especially useful in the hypotensive patient.
– DPL is fast and inexpensive. It has a lowDPL is fast and inexpensive. It has a low
complication rate in experienced hands.complication rate in experienced hands.
– FAST has replaced DPL in many institutionsFAST has replaced DPL in many institutions
because it is less invasive, but it has not yetbecause it is less invasive, but it has not yet
been shown to be more sensitive or specificbeen shown to be more sensitive or specific
than DPL in most published studiesthan DPL in most published studies
2) Penetrating abdominal truma2) Penetrating abdominal truma

50. Lab workupLab workup
 All patients should undergo certain basic laboratory testing,All patients should undergo certain basic laboratory testing,
as follows:as follows:
 Complete blood count (CBC) provides a baseline value forComplete blood count (CBC) provides a baseline value for
later comparison, even though it may not reveal the extentlater comparison, even though it may not reveal the extent
of active bleeding.of active bleeding.
 Basic chemistry profile (BMP) also reveals any baselineBasic chemistry profile (BMP) also reveals any baseline
renal insufficiency or electrolyte abnormalities.renal insufficiency or electrolyte abnormalities.
 Coagulation studies (PT/INR + PTT) may suggestCoagulation studies (PT/INR + PTT) may suggest
development of coagulopathy.development of coagulopathy.
 Arterial blood gas (ABG) provides important informationArterial blood gas (ABG) provides important information
regarding acid-base balance and, thus, the hemodynamicregarding acid-base balance and, thus, the hemodynamic
stability of the patient.stability of the patient.
 Urine dipstick may reveal occult blood indicative ofUrine dipstick may reveal occult blood indicative of
genitourinary tract injuries. Female patients should havegenitourinary tract injuries. Female patients should have
urine pregnancy testingurine pregnancy testing
2) Penetrating abdominal truma2) Penetrating abdominal truma

51. treatmenttreatment
1)Medical1)Medical
The trend in management of splenic injury
continues to favor nonoperative or conservative
management. This varies from institution to
institution but usually includes patients with
stable hemodynamic signs, stable hemoglobin
levels over 12-48 hours, minimal transfusion
requirements (2 U or less), CT scan injury scale
grade of 1 or 2 without a blush, and patients
younger than 55 years. For instances in which
patients have significant injury to other systems,
surgical intervention may be considered even in
the presence of the previously noted findings.
2) Penetrating abdominal truma2) Penetrating abdominal truma

52. 2)Interventional radiology2)Interventional radiology
Splenic angioembolization is increasingly
being used in both stable responders and
transient responders for fluid resuscitation
under constant supervision by a surgeon
with an operating room on standby
2) Penetrating abdominal truma2) Penetrating abdominal truma

53. 3) Surgical Therapy3) Surgical Therapy
 Surgical therapy is usually reserved forSurgical therapy is usually reserved for
patients with signs of ongoing bleeding orpatients with signs of ongoing bleeding or
hemodynamic instability. In somehemodynamic instability. In some
institutions, CT scan–assessed grade Vinstitutions, CT scan–assessed grade V
splenic injuries with stable vitals may besplenic injuries with stable vitals may be
observed closely without operativeobserved closely without operative
intervention, but most patients with theseintervention, but most patients with these
injuries will undergo an exploratoryinjuries will undergo an exploratory
laparotomy for more precise staging,laparotomy for more precise staging,
repair, or removalrepair, or removal
2) Penetrating abdominal truma2) Penetrating abdominal truma

54.  In less emergent situations, splenorrhaphy is theIn less emergent situations, splenorrhaphy is the
preferred method of surgical care. Multiplepreferred method of surgical care. Multiple
techniques are described in the literature, buttechniques are described in the literature, but
they all attempt to tamponade active bleedingthey all attempt to tamponade active bleeding
either by partial resection and selective vesseleither by partial resection and selective vessel
ligation or by putting external pressure on theligation or by putting external pressure on the
spleen via an absorbable mesh bag or sutures.spleen via an absorbable mesh bag or sutures.
Both “make it yourself” and commercial productsBoth “make it yourself” and commercial products
are available for this purpose. In patients withare available for this purpose. In patients with
capsular injury, the electrocautery or argon beamcapsular injury, the electrocautery or argon beam
coagulator device may provide adequatecoagulator device may provide adequate
hemostasis and allow for splenic preservation.hemostasis and allow for splenic preservation.
2) Penetrating abdominal truma2) Penetrating abdominal truma

55.  PostoperativePostoperative
 appropriate antibiotics for 5-7 daysappropriate antibiotics for 5-7 days
 arteriography with embolization can be used to stoparteriography with embolization can be used to stop
the small percentage of arterial bleeding found inthe small percentage of arterial bleeding found in
pelvic fracturespelvic fractures
 Follow-upFollow-up
 closely monitor vital signs and frequently repeat theclosely monitor vital signs and frequently repeat the
physical examinationphysical examination
““ An increased temperature or respiratory rate canAn increased temperature or respiratory rate can
indicate a viscus perforation or abscess formation.indicate a viscus perforation or abscess formation.
Pulse and blood pressure can also change with sepsisPulse and blood pressure can also change with sepsis
or intra-abdominal bleeding. The development ofor intra-abdominal bleeding. The development of
peritonitis based on physical examination findings isperitonitis based on physical examination findings is
an indication for surgical intervention.an indication for surgical intervention.
2) Penetrating abdominal truma2) Penetrating abdominal truma2) Penetrating abdominal truma2) Penetrating abdominal truma

56. COMPLICATIONSCOMPLICATIONS
 Complications of nonoperative care include delayedComplications of nonoperative care include delayed
bleeding, splenic cyst formation, and splenic necrosis.bleeding, splenic cyst formation, and splenic necrosis.
Complications of splenorrhaphy include rebleeding andComplications of splenorrhaphy include rebleeding and
thrombosis of the residual spleen as well as complicationsthrombosis of the residual spleen as well as complications
related solely to the laparotomy.related solely to the laparotomy.
 Complications of splenectomy include bleeding from shortComplications of splenectomy include bleeding from short
gastrics or splenic vessels and the most feared but mostgastrics or splenic vessels and the most feared but most
rare complication, infection by encapsulated organismsrare complication, infection by encapsulated organisms
such assuch as PneumococcusPneumococcus..
 Material used for compression wrap of the spleen inMaterial used for compression wrap of the spleen in
splenorrhaphy is often woven and may mimic bubbles in ansplenorrhaphy is often woven and may mimic bubbles in an
abscess on postoperative CT scans. Gel foam used forabscess on postoperative CT scans. Gel foam used for
angioembolization may also falsely mimic an abscess on CTangioembolization may also falsely mimic an abscess on CT
scans. Communication with the radiologist about thescans. Communication with the radiologist about the
presence of splenic wrapping material on any postoperativepresence of splenic wrapping material on any postoperative
CT scans will decrease the chance of this false-positiveCT scans will decrease the chance of this false-positive
resultresult
2) Penetrating abdominal truma2) Penetrating abdominal truma

57.  Angioembolization of the spleen can result inAngioembolization of the spleen can result in
noninfectious-related febrile events, sympatheticnoninfectious-related febrile events, sympathetic
pleural effusions, and left upper quadrantpleural effusions, and left upper quadrant
abscesses. Femoral arteriovenous fistulas andabscesses. Femoral arteriovenous fistulas and
iliofemoral pseudoaneurysms have also beeniliofemoral pseudoaneurysms have also been
reported (Killeen, 2001; Ekeh, 2005).reported (Killeen, 2001; Ekeh, 2005).
 Posttraumatic splenic pseudocysts are beingPosttraumatic splenic pseudocysts are being
reported more frequently now that nonoperativereported more frequently now that nonoperative
management has become the norm (Wu et al,management has become the norm (Wu et al,
2006). Optimal management is still unknown but2006). Optimal management is still unknown but
probably requires partial or completeprobably requires partial or complete
splenectomy to minimize morbidity and mortalitysplenectomy to minimize morbidity and mortality
2) Penetrating abdominal truma2) Penetrating abdominal truma

58.  Thrombocytosis with platelet counts aboveThrombocytosis with platelet counts above
1 million/mm3 have been linked to1 million/mm3 have been linked to
thrombotic vascular events such as deepthrombotic vascular events such as deep
vein thrombosis, pulmonary embolus, orvein thrombosis, pulmonary embolus, or
occlusive stroke. Although very little goodocclusive stroke. Although very little good
data exist, many surgeons treat persistentdata exist, many surgeons treat persistent
thrombocytosis with a daily baby aspirin.thrombocytosis with a daily baby aspirin.
 Pancreatic injury, pancreatitis, subphrenicPancreatic injury, pancreatitis, subphrenic
abscess, gastric distension, and focalabscess, gastric distension, and focal
gastric necrosis have also been reportedgastric necrosis have also been reported
after splenectomy for trauma.after splenectomy for trauma.
2) Penetrating abdominal truma2) Penetrating abdominal truma

59. Thanks for your attention …Thanks for your attention …
Dr. Aamer Jalal Othman HamzaDr. Aamer Jalal Othman Hamza