医学资料腹部创伤 课件

Abdominal & GU Trauma,October 10, 2002 Moritz Haager Dr. Michael Betzner,Objectives,Anatomical review Examine relationship between mechanism of injury, and resultant injury patterns Review diagnostic & therapeutic options Develop an approach to abdominal trauma,My 2 ,Trauma is highly variable in presentation, extent of injury, and examination Easy to lose sight of the forest for the trees A structured (i.e. ATLS) approach helps 3 ideas to keep in mind: Clinical suspicion avoids missed injuries Frequent reassessment avoids missed injuries Know the limitations of your tests,Case,22 yo male, roll-over MVA GCS 12, HR 120, BP 100/60, RR 24 CHI, RUQ contusion, obvious R lower leg # Resuscitated with 2L NS, vitals improve to GCS 12, HR 80, BP 115/70, RR 18 CT shows grade IV liver lacn Does he need OR?,Anatomy 101,Ant abdomen: nipple line ant axillary lines inguinal ligaments Flank: 6th ICS iliac crest Ant post axillary line Back: Tip of scapulae iliac crest Post axillary lines,Abdominal Cavities,Peritoneum: Upper: liver, spleen, diaphragm, stomach, transverse colon Lower: small bowel, sigmoid colon Retroperitoneum: Abd aorta, inf vena cava, duodenum, pancreas, kidneys, ureters, ascending / descending colon Pelvis: Rectum, bladder, iliac vessels, internal genitalia,Blunt Abdominal Trauma,Blunt mechanism accounts for 94% injury (pediatric + adult) locally Higher mortality Difficult Dx Usually multi-system / multi-organ injury MVA is leading cause (52.4% adult, 46.2% peds) Falls (25%), and violence (7%) CRHA Regional Trauma Services Annual Report 2000-2001 3 mechanisms: Deceleration / compression Crush injury Shearing / avulsion,History,AMPLE Hx Mechanism of injury: Penetrating vs. blunt MVA: Speed Type (roll-over, rear-end, frontal, etc) Restraints / air bags Damage / intrusion Status of passengers,Exam,ABCs / Primary Survey Inspection: Abrasions, contusions, lacs, penetrating wounds, impaled FBs, evisceration, pregnancy, blood at urethral meatus, scrotal / perineal ecchymoses Auscultation: BS yes or no Percussion / Palpation: Peritoneal findings Pelvis stable Prostate postion Accuracy of exam in BAT is 55-65%,Injury patterns in BAT,Spleen is most commonly injured organ Seatbelt injuries Rib fractures Abdominal injuries Mesenteric lacerations hemoperitoneum Bowel contusions / perforations delayed S/S Diaphragmatic rupture Abd aortic dissection (rare) Iatrogenic Ventilation GI distention / rupture CPR solid organ injury Tube thoracostomy solid organ injury,Name 6 differences in BAT in kids,Weaker abdominal musculature & less fat Smaller AP diameter Major organs in close proximity Compliant rib cage Previously undiscovered disease E.g. coagulopathies Occult non-accidental trauma (= #1 cause of death in 1 yo age group) Bottomline: Increased risk for multi-organ injury,Blunt Trauma Algorithm:,Approach to BAT,“the abdomen should neither be ignored nor the sole focus of the EP”Rosen Diverse spectrum of possible injury in BAT therefore clinical suspicion is key Answer a series of questions: Are there clinical indications for immediate OR? Is the patient hemodynamically stable? Is the exam reliable? Is there evidence for intraperitoneal injury, and if so does it require operative intervention?,Indications for Laparotomy,Unexplained hypotension / evidence for bleeding Clear, persistent peritoneal irritation Pneumoperitoneum Diaphragmatic rupture Persistent significant GI bleeding,Hemodynamically stable?,No seek IPH with DPL or U/S CXR and AP pelvis for non-peritoneal causes Laparotomy if IPH Yes Seek intraperitoneal injury Diagnostic imaging vs. serial exams Operative vs. non-operative management,Investigations in BAT,Unstable pt None CXR, AP pelvis DPL FAST Role of the “trauma panel”,Stable pt CT FAST DPL Serial exams MRI ERCP Radionuclide studies Contrast studies Angiography,The Trauma Panel,Whats usually ordered: CBC, lytes, Cr, BUN, PT, PTT, T /S, T/C, UA, EtOH, ABG, What there is actually evidence for: Mostly retrospective studies Most demonstrate abnormalities, but fail to indicate any change in management Review concludes most useful tests are T/S, T/C, CBC, PT/PTT , ABG, and tox screen Asimos. Emerg Med Reports. 1997,Plain Radiography,CXR Ruptured hemidiaphragm, pneumoperitoneum, loss of psoas shadow, retroperitoneal air AP Pelvis Pelvic fracture Routine use in awake pt with stable, non-tender pelvis may be unnecessary AXR Not routinely indicated in BAT May show tract, or retained missiles in PAT,Diagnostic Peritoneal Lavage,“virtue is in the triage of the patient who is hemodynamically unstable and has multiple injuriesespecially valuable in the discovery of potentially lethal bowel perforations”Rosen Sens 98-100%, Spec 90-96%, Acc 98-100% Positive DPL in setting of BAT: Aspiration of 10 ml gross blood 100,000 RBC/mm3 500 WBC/mm3 Bile, bacteria, vegetable matter, or incd amylase levels,Diagnostic Peritoneal Lavage,Advantages Rapid Aids operative decision-making Good for detecting hollow viscus injury Disadvantages Samples only peritoneal cavity Invasive False positive rate of 2% (Incs laps) Non-specific,Computed Tomography,Test of choice in STABLE pts Advantages: Defines location and extent of injury Ability to image multiple areas accurately Aids in non-operative management Disadvantages: Insensitive for pancreatic, diaphragmatic, and bowel injuries IV contrast Not suitable for unstable pts,FAST Focused Assessment w/ Sonography for Trauma,Rapid U/S exam focusing on: Pericardium Perihepatic: Morrisons Pouch Perisplenic: Splenorenal recess Pelvis: Pouch of Douglas (), rectovesicular pouch (),FAST,Advantages: Rapid (5 min), non-invasive, bed-side Sensitivity close to DPL Can follow w/ serial exams Disadvantages: Poor imaging of retroperitoneum, diaphragm, bowel, or solid organ damage Technically difficult in agitation, obesity, or bowel gas; operator dependent Sensitivity in kids adults,FAST,How to interpret a study: Positive: fluid in pericardium or any 1 of 3 abdominal windows Negative: No fluid in any windows Indeterminate: If any one of the 4 windows is inadequately visualized,Normal study,Hemopericardium,Normal Study,Perihepatic fluid,Perisplenic fluid,FAST,How good is it? Hemoperitoneum (Sens: 78-99%, Spec: 97-100%) Hemopericardium (Sens: 100%, Spec: 97%) Assumes important injuries will have assd free fluid However recent meta-analysis found NPV for IPFF and organ injury to be 0.78-0.94 + 0.72-0.99 respectively By calculating LRs this means assuming pre-test prob of 50%, the post-test prob after ve FAST remains 25% Concluded that a negative study does not adequately exclude IP injury Stengel et al. Br J Surg. 88: 901-912. 2001 Not adequately studied in pediatric trauma Jones. Trauma Reports. 2000,Should we learn to FAST?,U/S training mandatory as part of surgical residency in Germany FAST consensus committee recommends incorporation into residency training Studies have shown easy to achieve competency in detecting free fluid Jones. Trauma Reports 2000 No sig differences noted b/w experts & beginners in detecting FF Stengel et al. Br J Surg. 88: 901-912. 2001,Others,Contrast Studies: Gastrograffin for bowel perforations Urethrogram / retrograde cystogram Angiography Localization of bleeding / embolization ERCP delineation of pancreatic injury / stent placement MRI Spinal fractures, diaphragmatic defects Radionuclide Solid organ imaging if CT unavailable,BAT Management,Boils down to who needs urgent OR and who can be observed Laparotomy for all used to be standard Non-operative management increased from 10% to 54% over 6 year period in one study Schwab. World J Surg. 25: 1389-92. 2001 Really a surgical decision, but we need to understand what Kortbeek and Co are doing and why,BAT: Why NOT operate?,Non-therapeutic laparotomy rate 14-27% if indications just based on DPL + physical exam g number of non-therapeutic laps s morbidity + mortality Avoids 2nd hit hypotension Some injuries appear to do better w/o OR Improved tools to monitor pts Schwab. World J Surg. 25: 1389-92. 2001,BAT: Non-operative Management,Factors no longer felt to represent absolute indications for OR: Advanced age Grade of solid organ injury* Initial BP Hemoperitoneum (presence or size) Altered mental status Schwab. World J Surg. 25: 1389-92. 2001,BAT: Non-operative Management,Who is NOT a candidate? Hemodynamically unstable Acute abdomen / peritonitis Hollow viscus injury Evidence of intraabdominal injury requiring operative repair on CT Ochsner. World J Surg. 25: 1393-96. 2001 “The patient who is best served by early celiotomyis one who cannot be stabilized with volume infusion.” Schwab. World J Surg. 25: 1389-92. 2001,BAT: Non-operative Management,Who is likely to fail non-operative mgmt? Hemodynamic instability despite resuscitation* Contrast blush on CT* Contrast pooling on CT* ?Grade IV-V liver injuries ?Grade IV and higher splenic injury ?Increasing size of hemoperitoneum Further prospective evaluation is needed Ochsner. World J Surg. 25: 1393-96. 2001,Non-operative Mgmt: Liver,In general CT appearance of solid visceral injury correlates poorly with need for OR Contrast pooling strongest predictor for OR Non-operative mgmt expected to be successful in 90% of hemodynamically stable pts with documented liver injury Mandates very close F/U with serial exams Pitfalls: Missed co-existant injuries reqg OR Attributing ongoing blood loss to other sources Transfusing 4 U PRBCs Misinterpreting CT scan Kimball. World J Surg. 25: 1403-04. 2001,Non-operative Mgmt: Spleen,Why not splenectomize? OPSI: 80% mortality, life-long risk Clear association b/w grade of splenic injury and increased rate of operative intervention I , II non-operative Tx 90% w/ 10-20% failure rate F/U CT scan at 6-8 wks III, IV partial resection, mesh splenorraphy V splenectomy CT findings indicating need for OR controversial Contrast blush most consistent Angiography + embolization evolving Urans and Pfeifer. World J Surg. 25: 1405-07. 2001,Penetrating Abdominal Trauma,US data: GSWs account for 90% of penetrating trauma mortality despite stab wounds being 3x as common Locally penetrating trauma (all types) accounts for 3-5% of injuries Only 2 cases of assault with firearm in 00-01 in Calgary No pediatric penetrating trauma in 00-01 CRHA Regional Trauma Services Annual Report 2000-2001,My view on gun control:,and the NRA perspective:,Penetrating Abdominal Trauma,Pathophysiology: Stab wounds: Knives, fences, horned animals Most do NOT enter peritoneal cavity Liver small bowel other injuries IP injury related to site of stab wound Missiles: Bullets, explosions, machinery-related accidents Multiple IP injuries are the rule Small bowel colon liver other Impact velocity is primary determinant of severity BAT + PAT may coexist e.g. Pine Lake,Penetrating Abdominal Trauma,What do you want to know? Stab wounds: Cause of wound Number + location of wounds Body position at time of injury Time of injury, EBL at scene, response to Tx GSWs / Missiles: Type of weapon or missile Distance from the victim,Initial Management + Evaluation,ABCs / Primary survey Early antibiotics for suspected bowel perfn Management depends on mechanism: GSW: any torso GSW presumes IAI Stab: often stable w/ equivocal exam Unstable + peritoneal findings OR Stable Objective is to utilize diagnostic studies to determine if peritoneal penetration occured,Investigations,Trauma panel Plain films DPL FAST CT Local Wound Exploration Laparoscopy,DPL,Same technique and diagnostic criteria as in BAT, except RBC criteria depending on location:,Local Wound Exploration,Primary use in single anterior stab wounds to r/o peritoneal penetration Not used in: Multiple stab wounds entry over thorax Inability to clearly visualize end of wound tract presumes peritoneal violation,Laparoscopy,Limited utility Usually requires GA Risk of tension pneumothorax / gas embolus High false negative rate No info on post peritoneum / retroperitoneum Primary use: Isolated stab injuries of ant abd can d/c if -ve,PAT Management Overview,PAT: Overview,Approach to GSW + stab wound similar but: Stab: Low incidence of peritoneal penetration Operative intervention for all would result in unacceptable non-therapeutic lap rate GSW: High incidence of peritoneal entry and injury (80%) Selective management is increasing but stab wounds Approach outlined by 3 basic questions: 1. Does this person need OR now? 2. Has peritoneal penetration occurred 3. Does an IAI exist, and does it need the OR?,Clinical Indications for Laparotomy in PAT,Hemodynamic instability Peritoneal signs Evisceration Diaphragmatic injury GI or vaginal hemorrhage Implement in situ Intraperitoneal air,Rule Out Peritoneal Penetration,Stab wounds: DPL LWE CT Laparoscopy U/S,GSWs: Missile path Plain films LWE U/S Laparoscopy CT,Is there an injury requiring OR?,Stab wounds: DPL CT Serial examinations (min 24 hrs),GSWs: Serial exams DPL Laparoscopy,GSW + Non-operative Mgmt,Highly controversial Non-therapeutic lap rate 15-25% w/ traditional approach Significant number of pts w/o peritoneal penetration, or minimal IAI 9 trials of non-OR mgmt: No deaths 300 pts managed non-operatively Heterogenous, 6 studies from same center Non-operative Tx for GSW is evolving, but laparotomy remains standard for most Saadia and Degiannis. Br J Surg. 87: 393-397. 2000,Other Situations:,Thoracoabdominal wounds: FAST to r/o hemopericardium DPL: lower criterias sensitivity for diaphragm lacerations Back / Flank wounds: d risk of retroperitoneal + diaphragm injury LWE, CT, serial exams, OR for most GSWs Implements in situ Should be removed in OR May need angiogram or CT to r/o vascular involvement,GU Trauma,Rarely life-threatening Most common BAT injuries in kids Should be identified as part of secondary survey More likely to be occult injuries Investigated in retrograde fashion: Urethra bladder ureter kidney Hematuria is hallmark sign,GU Exam,Following increase likelihood of GU injury & demand investigation: Abdo tenderness or PAT Pelvic fracture / tenderness Blood at urethral meatus / vaginal introitus Penile / scrotal / perineal ecchymoses or pain Abnormal prostate / rectal exam Any color urine other than clear yellow DONT even think about placing a foley,Hematuria in Trauma,Indications for investigation: Adults: Gross hematuria Microhematuria feel any microhematuria should be investigated Christopher. Ped Emerg Med Reports. 2000,Foley Cath: Dos + Donts,Do: Place foley in absence of previous S & S Single attempt in documented partial tears Place suprapubic cath in complete tears Dont: Place foley in suspected injury until retrograde urethrogram has been performed Remove a in situ foley,Anatomy,Bladder,Prostatic urethra,Urogenital diaphragm,Bulbous urethra,Pendulous urethra,Membranous urethra,Urethral Injury,V. rare in s severe pelvic # Straddle injury ant injury (#1 peds cause) Setting of BAT usually causes post injury Prostatic urethra fixed to symphysis pubis Fractures cause avulsion & urethral tearing Dx is made with retrograde urethrogram Tx: Partial: attempt foley once Complete: suprapubic cath +& urology consult,Bladder Rupture,Intrapelvic (empty) umbillicus (full) Kids adults b/c bladder more intraabdominal 3 muscle layers arranged at angles seal small perforations Assd w/ severe trauma (90%) & high mortality Extraperitoneal & intraperitoneal Present w/ abd or pelvic pain, inability to void, & gross hematuria (95%) Investigations: Retrograde cystography Retrograde CT cystography Standard CT abd/pelvis is NOT adequate,Bladder Rupture,Extraperitoneal (80-90%): Assd w/ pelvic # Flame-shaped extravasation of contrast in obturator region / prevesicular space of Retzius Tx: 20 F foley x7-14 days Intraperitoneal (10-20%): Assd w/ blunt trauma & full bladder Intraperitoneal organs outlined by contrast Tx: surgical repair,Renal Trauma,Most