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Abdominal Trauma Flashcards

(49 cards)

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1
Q

Pre-op preparation for trauma laparotomy

A
  • Adequate IV access
  • Prophylactic antibiotics
  • Reserve 6 units PC, FFP, plt con
  • Inform OT to prepare two large suction catheter, all necessary equipment, vascular clamp
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2
Q

Procedure for trauma laparotomy

A
  • Drape from suprasternal notch to mid-thigh
  • Long midline laparotomy
  • Inform anaes before entering peritoneum
  • Stop bleeding and spillage (remove clots then 4 quadrant packing)
  • Remove packing to identify bleeding
  • Deal with lesion in order of lethality
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3
Q

Order the following by greatest lethality:

Solid organ bleeding

Hollow viscus contamination

Mesentery bleeding

Major vessel bleeding

A

Major vessel bleeding

Solid organ bleeding

Mesentery bleeding

Hollow viscus contamination

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4
Q

Level of splenic injury determined by which factors

A
  • Size of hematoma
  • Extent of laceration
  • Involvement of segmental / hilar vessels
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5
Q

Level I splenic injury

A
  • subcapsular hematoma, <10% surface area
  • capsular laceration, <1cm parenchymal depth
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6
Q

Level II splenic injury

A
  • Hematoma
    • subcapsular, 10-50% surface area
    • intraparenchymal <5cm in diameter
  • Capsular tear not involving trabaecular vessel, 1-3 cm parenchymal depth
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7
Q

Level III splenic injury

A
  • Hematoma
    • Expanding subcapsular
    • Ruptured
    • Intraparenchymal > 5cm
  • Laceration >3cm or involving trabecular vessels
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8
Q

Level IV splenic injury

A

Laceration involving segmental or hilar vessels, leading to major devascularization (>25% of spleen)

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9
Q

Level IV splenic injury

A

Laceration involving segmental or hilar vessels, leading to major devascularization (>25% of spleen)

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10
Q

Level V splenic injury

A

Completely shattereed spleen

Hilar vascular injury which devascularizes spleen

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11
Q

Indication for laparotomy in splenic injury

A
  • Unstable
  • Penetrating injury
  • Other concomitant injury requiring laparotomy
  • Failed non-operative treatment
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12
Q

Procedure for splenectomy

A
  • Surgeon on right, left hand holding spleen
  • Mobilize lienorenal, splenophrenic, splenocolic ligament
  • Deliver spleen medially towards lap wound
  • Apply soft bowel clamp at hilum
  • Ligate short gastric arteries
  • Ligate splenic artery then splenic vessel
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12
Q

Procedure for splenectomy

A
  • Surgeon on right, left hand holding spleen
  • Mobilize lienorenal, splenophrenic, splenocolic ligament
  • Deliver spleen medially towards lap wound
  • Apply soft bowel clamp at hilum
  • Ligate short gastric arteries
  • Ligate splenic artery then splenic vessel
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13
Q

What is OPSI?

A

Overwhelming post splenic infection.

Life-threatening infection due to encapsulated bacteria

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13
Q

What is OPSI?

A

Overwhelming post splenic infection.

Life-threatening infection due to encapsulated bacteria

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14
Q

Most common encapsulated organisms that could cause OPSI

A

Streptococcus pneumoniae

Hemophilus influenzae

Neisseria menigitidis

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15
Q

Non-operative management of traumatic splenic injury

A
  • Bedrest
  • NPO
  • Close monitoring
  • Angioembolization
  • Surveillance CT in 24-48 hours
    *
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16
Q

Indications for surgery in traumatic liver injury

A
  • hemodynamically unstable
  • penetrating liver injury
  • concomitant internal injury
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17
Q

Techniques for liver hemostasis during laparotomy

A
  • Bimanual compression
  • Pringle maneuver
  • Perihepatic packing
  • Topical hemostatic agents
  • Parenchymal vessel ligation
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18
Q

Grade 1 Liver injury

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A

Hematoma <10% of surface area

Capsular tear < 1 cm parenchymal

19
Q

Grade 2 liver injury

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A

Subcapasular hematoma 10-50% or intraparenchymal <10cm

Capsular tear 1-3cm parenchymal depth, not involving trabecular vessel

20
Q

Grade 3 liver injury

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A

subcapsular hematoma > 50% surface area OR

ruptured hematoma

intra-parenchymal hematoma > 10 cm / expanding OR

Laceration > 3cm parenchymal depth

21
Q

Grade 4 liver injury

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A

Parenchymal disruption involving 25-75% of hepatic lobe or >3 Couinaud’s segemnts within 1 lobe

22
Q

Grade 5 liver injury

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A

Parenchymal disruption involving > 75% hepatic lobe, >3 Couinaud’s segment within single lobe

Juxtahepatic venous injury

Hepatic avulsion

23
Pringle's maneuver
Compression of porta hepatis No greater than 30 minutes
24
Possible complications of traumatic liver injury
* Hemorrhage * Biloma * Hemobilia * Hepatic necrosis * Cholecystitis * SIRS secondary to bile peritonitis
25
Non-operative management for Grade IV/V +/- III
* Close monitoring with ICU admission * A-line * Hemocue, u/O q1H * FU CT in 48-72 hours
26
Factors for grading of duodenal injury
* single or multi-segment * extent of hematoma * extent of laceration * location of disruption (D1,2,3,4)
27
How to expose the duodenum and pancreas during laparotomy?
* Kocherization of duodenum * Divide gastrocolic ligament (expose posterior D1, medial D2, anterior pancreas) * Divide retroperitoneum inferior to pancreas (inspect posterior pancreas) * Right medial visceral rotation (expose D3) * Mobilize ligament of Treitz (D4)
28
Treatment for low grade duodenal injuries
Debridement + primary repair * Grade 1: suturing serosa in Lembert fashion * Grade 2: * debridement + full thickness repair * \>3cm: resection + primary anastomosis
29
Treatment options for intermediate grade duodenal injury
* debridement + primary closure * resection + primary anastomosis * duodeno-duodenostomy * larger defect: roux en y
30
Treatments for ampulla injury
* limited ampullary injury: stenting or sphincteroplasty * extensive ampullary injury: whipple operation
31
Treatment options for isolated extensive duodenal injuries
* Pyloric exclusion * Duodenal diverticulization * Pancreaticoduodenectomy
32
What is duodenal diverticulization of Berne? Draw.
* suture repair of injury * antrectomy + end-side gastrojejunostomy (Polya) * tube duodenostomy * T tube drainage of CBD
33
Factors involved in grading of pancreatic injury
* ductal injury / tissue loss * involvement of main pancreatic duct + relationship to SMV * distal / proximal transection
34
Definition of abdominal compartment syndrome
Sustained intraabdominal pressure \>20mmHg associated with new organ failure
35
Risk factors for IAH/ACS
* diminished abdominal wall compliance (increase intra-thoracic pressure, major trauma/burns, prone etc) * increase intra-luminal contents * increase abdominal contents * Capillary leak/fluid resuscitation
36
How to measure patient's IAP
Bladder technique * Insert 3 way foley * Instill 25ml saline into balloon * Measure 30-60 sec after instillation for pressure after detrusor muscle relaxation * Measure in absence of abdominal wall contraction \*\*measure in mmHg, at end-expiration, in supine position
37
IAH Grading
* Grade I: 12-15 mmHg * Grade II: 16-20mmHg * Grade III: 21-25 mmHg * Grade IV: \> 25mmHg
37
IAH Grading
* Grade I: 12-15 mmHg * Grade II: 16-20mmHg * Grade III: 21-25 mmHg * Grade IV: \> 25mmHg
38
What is primary ACS?
condition associated with injury/disease in the abdominopelvic region frequently requiring early surgical/radiological intervention
39
Five pillars of medical treatment for ACS
1. Evacuate intraluminal contents 2. Evacuate intra-abdominal SOL 3. Improve abdominal wall compliance 4. Optimize fluid administration 5. Optimize systemic/regional perfusion
40
Elaborate on progressive steps to **evacuate intraluminal contents** for medical management of ACS
* insert nasogastric/rectal tube for decompression * initiate prokinetic agents * minimize enteral nutrition * administer enemas * consider colonoscopic decompression * discontinue enteral nutrition * consider surgical decompression if IAP still \> 25 mmHg
41
Elaborate on progressive steps to **evacuate intra-abdominal space occupying lesions** for medical management of ACS
* abdominal USG/CT to identify lesions * Percutaneous catheter drainage * Consider surgical evacuation of lesions
42
Elaborate on progressive steps to **improve abdominal wall compliance** for medical management of ACS
* Ensure adequate sedation & analgesics * Remove constrictive dressings/ abdominal escars * Avoid prone position, avoid elevate head of bed \>20 degrees * Consider reverse Trendelenburg * Consider neuromuscular blockade
43
Elaborate on progressive steps to **optimization of fluid administration** for medical management of ACS
* avoid excessive fluid administration * aim for zero to negative fluid balance by D3 * resuscitate with hypertonic fluids/ colloids * Fluid removal via judicious diuresis * Consider hemodialysis /ultrafiltration
44
Elaborate on progressive steps to **optimize systemic/regional perfusion** for medical management of ACS
* Goal-directed fluid resuscitation * Maintain abdominal perfusion pressure \> 60mmHg * Hemodynamic monitoring to guide resuscitation * Vasoactive medication to keep APP \> 60mmHg
45
Describe the sandwich technique
* Sheet of self-adhesive drape (Ioban/Opsite) placed flat * Place abdominal pad on top * Fold edges of Ioban over abdominal pad producing membrane of one side of abdominal pad * Place on on-lay manner with membrane in contact with bowel * Place two closed system suction drains and apply low vaccum suction * Cover system by another occlusive adhesive drape
46
Complications of open abdomen
Fluid loss Protein loss Fistula formation Loss of domain (fascial retraction)

Critical Care (12 decks)

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