Chapter 183 - Abdominal trauma Flashcards
Retroperitoneal trauma zones
Zone 1: midline from aortic hiatus to sacral promonitory
- supramesocolic: celiac, sma, renal, ivc, smv
- inframesocolic: infrarenal aorta, ivc
Zone 2: L+R kidneys, paracolic gutter, renal vessels
Zone 3: pelvic retroperitoneum; iliac vessels
Zone 4: perihepatic area with retrohepatic IVC + hepatic veins
Rate of vascular trauma in different indications for exploratory laparotomy
Gunshot - 14.3%
Stab - 10%
Blunt - 3%
Mechanisms of vascular injury after blunt trauma
1) rapid deceleration
2) direct anteroposterior crushing
3) laceration by bone fragment
Most common injured vessels in the abdomen in trauma in lists
IVC - 25% Aorta - 21% Iliac artery - 20% iliac veins - 17% SMV - 11% SMA - 10%
average number of vascular injuries in someone who had at least one
1.7
Rate of enroute deaths in vascular injuries from scene to hospital
14%
Signs of vascular injury after penetrating injury
1) abdominal distension
2) hypotension
3) asymmetric femoral pulses
Diagnostic evaluation for penetrating and blunt trauma
Penetrating: unstable = laparotomy
Stable = CTA
Blunt: FAST positive and unstable = laparotomy
FAST negative and unstable = peritoneal aspirate +/- CTA
SBP target for permissive hypotension
80-90 mmHg
Survival rate after resuscitative thoracotomy for abdominal trauma
2%
Temperature of infused fluid
40-42C
Ratio of massive transfusion products
1:1:1
When not to explore penetrating hematomas
Contained zone 4 retrohepatic hematoma
All others need exploration
When to explore blunt hematoma
All zone 1
Zone 2+3 if:
1) expanding
2) pulsatile
3) leaking hematoma
4) absent ipsilateral pulse
5) paraduodenal (to r/o duodenal injury)
6) root of mesentery with mesenteric ischemia
Steps of left medial visceral rotation
1) divide peritoneal reflection lateral to left colon
2) divide splenic flexure and mobilize spleen
3) mobilize fundus of stomach, tail of pancreas, colon, spleen and left kidney to right
Exposure for IVC injury
right medial visceral rotation: right colon, hepatic flexure and Kocher mobilization of duodenum and head of pancreas
Exposure for zone 3 vessels
Dissection of paracolic peritoneum and medial rotation of right or left colon
Damage control procedures
1) ligate all complex venous injuries
2) shunt all arterial injuries
3) pack diffuse retroperitoneal or parenchymal bleeding
4) vac abdomen, never close primarily
Intraabdominal hypertension definition
12 mmHg
Abdominal compartment syndrome definition
20 mmHg with organ dysfunction
Symptoms of abdominal compartment syndrome
1) tense abdomen
2) tachycardia
3) hypotension
4) respiratory dysfunction
5) high peak inspiratory and plateau pressures
6) oliguria
Measurement of abdominal compartment pressure
1) 20 ml saline into bladder
2) measure pressure
Most common types of blunt aortic injury
intimal flap = 60%
free rupture 30%
pseudoaneurysm 10%
Management of intimal tears in aorta
if small, non-operative
Associated organ injuries in vascular penetrating injury
Small bowel 45%
colon 30%
liver 28%
Surgical treatment of penetrating aortic injury
1) lateral aortorrhaphy
2) prosthetic graft (even if spillage)
Mortality of penetrating vs blunt aortic trauma
Penetrating: 67-85%
Blunt: 30%
Length of the celiac trunk
1-1.5 cm long
Tripod of Haller
Common hepatic
left gastric
splenic
Exposure of the celiac artery
right visceral rotation
Ligation of celiac and common hepatic
both tolerated if good collaterals
