Resuscitation & Abdominal

trauma
Presenter : Muhammad Afif
Anis Zarina
Supervisor : Dr Wazir

Outline
DEFINITION AND INTRODUCTION
ASSESSMENT & RESUSCITATION
DEFINITIVE CARE
TAKE HOME MESSAGES

DEFINITION AND INTRODUCTION

TRAUMA cellular disruption caused by
environmental energy / physical force
6th leading cause of death worldwide(10% of
cases)
Leading cause of death in those aged 5 to 40
years
Majority of trauma cases is due to road traffic
accidents (70.1%)

Trauma related death has a

trimodal distribution

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

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

Assessment and resuscitation

Primary survey with concurrent resuscitation.
Requires a team of doctors, nurses, assistant
medical doctors and attendants.
Must be lead by a team leader.
Secondary survey with concurrent resuscitation.
Reassessment and on going resuscitation while
reviewing investigations.

Primary Survey
A = Airway maintenance with cervical protection
intubate if necessary.
B = Breathing and ventilation Look for signs of
respiratory distress and SPO2.
Non invasive or invasive oxygen therapy with
relief of life threatening conditions eg tension
pneumothorax.

 C = Circulation with hemorrhage control

2 large bore 16 Gauge branula, CBD, CVP

IV crystalloids 30ml/kg run fast
Stop external bleeder
Colloids and blood products.
Aim MAP 65mmHg

D = Disability ,neurological status

E = Exposure / environmental control

Evaluation of fluid resuscitation

The return of normal blood pressure, pulse
pressure and pulse rate
Improvements in CNS status and skin
circulation .
Urine Output : 0.5-1ml/kg/h
CVP
Acid base balance
Persistent metabolic acidosis is usually due to
inadequate resuscitation or ongoing blood loss.

After fluid bolus is given..

Rapid
response

Transient
response

No response

Return to
normal

Transient
improvement

Remain
abnormal

Estimated blood Minimal (10loss

20%)

Moderate and
ongoing (2040%)

Severe (>40%)

Need for more

crystalloid

Low

High

High

Need for blood

Low

Moderate to
high

Immediate

Blood
preparation

Type and cross

match

Type specific

Emergency
blood release

Need for
operative
intervention

Possibly

Likely

Highly likely

Need for
immediate

No

No

Yes

Vital signs

Transient or non responder

Most common: ongoing internal bleeding
- clinically : more pallor, persistent
tachycardic, tachypnea, abd distension
- FAST scan
- Aggressive fluid resuscitation (using 3:1 rule)
- Blood transfusion : 2pint pack cell
*consider DIVC regime

Secondary Survey

Follows the primary survey

Complete history including AMPLE
Complete head -to-toe examination
Reassessment of response to resuscitation.

Examination
Inspection

Palpation

Auscultation

Distended

Tenderness

Bowel sounds
-absent
-in thorax

Abrasion

Guarding

Laceration

Rigidity

Cullens, Grey turners,

Kehrs sign

Mass

Gross hematuria

PR high riding prostate

Hematoma or bruises

Cullens sign

Grey turners
sign

Kehrs sign

Investigations

Serial FBC, RP, PT/INR, ABG, Serum amylase

FAST US
X-ray chest and abdomen
USG Abdomen
CT scan

Focused Assessment with Sonography in

Trauma (FAST)
To detect hemoperitoneum & pericardial effusion
Sensitivity 86- 99%
Four different views:
-Pericardiac
-Perihepatic
-Perisplenic
-Peripelvic

Advantages of FAST
Can detect 100 mL of blood
Rapid , accurate, portable, reproducible
Cost effective, non invasive, no radiation
Eliminates unnecessary CT scans
Helps in management plan

Plain X-ray chest & Abdomen

CXR:
Free air under diaphragm
NG tube or bowel loops in the thoracic cavity
Elevation of both or single diaphragm
Lower ribs fractures
AXR:
Ground glass appearance-massive hemoperitoneum
Obliteration of psoas shadow-retroperitoneal bleed

CT scan
Gold standard
High sensitivity and specificity-95%
Provides excellent imaging of solid and hollow
organs, retroperitoneum, genitourinary system
(able to grade) and hemo/pneumoperitoneum.
Determines the source of bleeder.
Can reveal other associated injuries eg vessels.
Only in haemodynamically stable patients.

ABDOMINAL TRAUMA

MECHANISM OF INJURY
Blunt trauma

Penetrating injury

Fall from height

Stab wound

MVA

Gunshot wound

Domestic injury
Sport injury
Contact injury
Child abuse

Abdominal injuries
Intraperitoneal
Solid, hollow, mesentery

Retroperitoneal
Abdominal wall (hematoma) esp in warfarinized
or hemophilia patients after minor trauma.

Intraperitoneal
Solid organs
Spleen(40-55%)
Liver(35-45%)

Hollow organs
Gastric, bowel, bladder or GB perforation
Penetrating injury

Mesentery (bowel ischaemia)

Retroperitoneal
Pancreas (10-20%) traumatic pancreatitis
Vascular(5-10%) major vessels
Kidneys(5%)

Indications for laparotomy

Blunt abdominal trauma + hypotension +
positive FAST or clinical evidence of
intraperitoneal bleeding
Penetrating trauma : eg : Gunshot or abdominal
evisceration
Peritonitis
Free air, retroperitoneal air or rupture of
hemidiaphragm after blunt trauma
Organ specific injury - on CT scan

Splenic injury
20% due to left lower rib fractures

Conservative Management:

Hemodynamic stable
Negative abdominal examination
Absence of contrast extravasation in CT
Subcapsular Hematoma, Laceration <3cm

Serial abdominal examination and CT scan.

Success rate of conservative Mx >80%

Operative management
Splenorrhaphy with serial monitoring.
Total Splenectomy and vaccination.
Success rate of splenic salvage procedure is 4060%.
Others partial splenectomy, total splenectomy
with autotransplantation.

Liver injury

Largest organ - 2nd most commonly injured

85% with blunt hepatic trauma are stable
CT main stay of diagnosis in stable patient
Most treated conservatively
Watch out for on going bleed, hepatic necrosis,
infected billoma, biliary tree injuries.

Conservative management
Haemodynamically stable
No other intra abdominal injury require surgery
< 2 units of blood transfusion required in 6
hours
Hemoperitoneum <500ml on CT

Operative management
Liver packing
-

Bleeding can be stopped

Pack removed after 48hr

Pringles maneuver
- Direct compression of the portal triad
(digitally or soft clamp) to control the inflow
Lobar Resection
Liver Transplantation

Renal injury

Clinically not suspected & frequently overlooked

Clinical - Shock, hematuria & pain over the loin
Urine: gross or microscopic hematuria
CT scan Grading

Management
85% of blunt renal trauma can be manage
conservatively.
Indications for nephrectomy
Hemodynamic instability
Grade 5 renal injury

Risk of dialysis should be explained if planned for

nephrectomy.

Take home messages

Primary survey and resuscitation goes hand in
hand. Its an ongoing process.
Coagulopathy, hypothermia, and worsening
metabolic acidosis are lethat triad that need to
be watched out for in trauma patients
Fluid resuscitation is vital and evaluation of it is
important.
Negative FAST scan cannot exclude possibility of
significant intraabdominal injury if clinically is
indicated.

 CT scan is gold standard to diagnose

intraabdominal injury in hemodynamically
stable patient.
20% of splenic injury is due to lower rib
fractures
85% with blunt hepatic trauma are stable
85% of blunt renal trauma can be manage
conservatively

References
ATLS for Doctors, 9th edition
Bailey & Love Short Practice of Surgery, 25th
edition
http://www.surgeons.org.uk/advanced-trauma-l
ife-support/shock.html
Clinical companion in surgery

Thank you!