PONGSASIT SINGHATAS, M.D.

Department of Surgery
Faculty of Medicine, Ramathibodi Hospital
Mahidol University
Patient
survive
Low morbidity

GOOD JUDGMENT COMES FROM

EXPERIENCE

EXPERIENCE COMES FROM

BAD JUDGMENT
Airway and Breathing first

Solid organ and Vascular injury => C

Hollow viscous injury => Sepsis

Investigate and assessment of abdomen base
on three group
1)Normal abdomen
2)Equivocal require investigation
3)Obvious abdominal injury

Diagnosis modalities
1) PE
2) DPL
3) FAST
4) CT scan
5) Diagnostic laparoscope
Hemodynamically normal patient
Full evaluation and decision to surgery or
non-operative management

Hemodynamically stable patient

Will benefit from investigation aimed to
- Patient bled into abdomen ?
- Bleeding has stopped ?
- Hollow viscous injury ?
Hemodynamically unstable patient
Try to define bleeding is taking place e.g. pelvis
or abdominal cavity

FAST quicker than DPL but operator dependence

Negative DPL => very clear that the intra

abdominal bleeding is unlikely in unstable
patient
 Negative Exporation => Survive

Positive Unexploration => Dead

 เจ็บฟรี, เสียหน้า, เสียเวลา
 Operative
complication (GA, wound, adhesion)
 Communication with patient and relative

Except Negative Exploration in Pelvic Fx

 Unstable vital sign with
abdominal cause
or
Peritonitis
(Diffuse Abdominal tender)
 Bowel content
 Bile
 Urine
 Pancreatic juice
 Blood

Difficult to exam in
Head injury
Cord injury
Intoxication
Adequate analgesia
 Never mask abdominal symptom
 Make abdominal pathology easier to assess
- Clear physical sign
- Co-operative patient
FAST in unstable patient
 Positive=> explore laparotomy
 Equivocal => DPL/DPA or explore laparotomy
 Negative => Find other bleeding, if not found
DPL/DPA or explore laparotomy

 No ultrasound available =>DPL/DPA

Not sent unstable patient to CT room

Abdominal sign
 Pelvic fracture with lower abdominal sign
  CT or FAST not available
 No other source in hemodynamic unstable
 Distinguish blood from other type of fluid

DPA => gross blood in unstable patient

Trauma Mattox Edition6

 Not BP only
 Hypertensive patient ??
 Sign of poor tissue perfusion

4 classification of hypovolemic shock

And
Responsibility after fluid resuscitation
 Class I Class II Class III Class IV

For 70 kg male
2000 mLof isotonic solution in adult; 20 mL/Kg in children
 Solidorgan injury => liver, spleen, kidney,
pancreas
 Vascular injury with interventionist

 Need ICU
 Need OR available
 Need Surgeon available
 Necessary to CT scan ??
 - Triple contrast
- Solid parenchymal organ injury
- Free air (Plain film abdomen)
- Free fluid with Hounsfield Units
- Contrast extravasations (lumen and vessel)
- Injury grading

Limitation
- Hollow viscus
- Mesenteric injury
- Diaphragmatic injury
- Bladder injury (need CT cystogram)
Trauma Mattox Edition6
 Unstable Stable

FAST Positive EL CT

FAST Equivocal DPA +/- EL CT

FAST Negative Find other Repeat FAST

bleeding, if not Observe
found DPA +/- EL CT ??

CT not available
???
 Not routinely
 Stab wound
 Anterior abdomen
 No indication in Flank or back
 Under local anesthesia
 Positive => Penetration of posterior fascia

Rarely practice in trauma center

Trauma Mattox Edition6
Serial PE DPL
 Observe 24 hr  Unstable with other
 Ideal same surgeon cause bleeding
 Frequent check V/S
 Abdominal sigh every  StableR/O hollow
4 hr viscus or
diaphragmatic
injury
 Persist
local
symptom => other
modality evaluated FAST
 Not recomment
 Routine laparotomy both stab and
GSW

Increase conservative in stab wound

Laparotomy in GSW

More conservative in GSW

 Notroutine in  Triple contrast
anterior stab  Wound tract
wound evaluated
 Free air, free fluid
 Recommend in  Contrast
- Stab wound at extravasate
flank and back (15%  Intraluminal
require surgical repair)
contrast leak
- GSW
 Bowel wall defect
Trauma Mattox Edition6
 Peritonitis
 Unstable vital sign
 Blood replacement??
 Most common cause in trauma

 Presumed hemorrhagic shock until proven

otherwise

 Fluid
resuscitation in early signs and
symptoms of blood loss

Principle is Stop the bleeding

and replace the volume loss
 Wholeblood is superior than component
therapy

 PRBC:FFP ratio of 1:1 or 2:1

 Platelet
require in blood loss greater than
1.5 blood volume
 อุดรูรั่วและเติมน้าให้ทัน
ถ้าตุ่มแห้ง => เลือดหมดตัว => ตาย
Exsanguination = Extensive Hemorrhage
- Large syringe connect to pressure source
(human hand)
- IV pressure bag
- Pneumatic external pressurized
intravenous infusion system

Increasing hematocrit and decreasing

temperature => Increase blood viscosity
 Controlled resuscitation, balance
resuscitation, permissive hypotension

 KeepSBP 80-90 mmHg or 100 mmHg if

head injury is suspected

 Penetrating trauma with hemorrhage

 No evidence in blunt trauma

Manual of Definitive Surgical

Trauma Care, Boffard
 Delay aggressive fluid resuscitation
until definitive control

 Prevent additional bleeding

Balance of organ perfusion
and
Risk of rebleeding
(accept a low normal blood pressure)
Manual of Definitive Surgical
Trauma Care, Boffard
 Desire to reassess the intra-abdominal content
(directed re-look)
 Evidence of decline of physiology reverse
1)Initial body temperature < 34 C

2)Initial acid-base status

- Arterial pH <7.2
- Serum lactate > 5 mmol/L
- Base deficit <-15 mmol/L in patient <55 years
or <-6 mmol/L in patient >55 years

Manual of Definitive Surgical

Trauma Care, Boffard
3)Onset coagulopathy
PT >16 sec or PTT >60 sec
>50% of normal

4)Other condition
- >10 unit blood
- SBP <90 mmHg more than 60 min
- Operating time >60 min

Control
1. Bleeding
2. Contamination
 Thoracotomy if indication
 Laparotomy if indication
 In unstable patient, what is first?
=> depend on ICD content
=> prep both chest and abdomen
Diaphragmatic injury
 Difficultto diagnosis
 Both hemothorax and hemoperitonem in one
penetrate wound
 Bowel content or NG tube at chest (Lt) from
film chest in blunt

 Should be repair by non absorbable

 Laparoscopic diagnosis and repair is
standard
 Can repair from thoracotomy or laparotomy
 11 in 28 (39%) mortality in unstable pelvic Fx
with laporotomy
 FAST positive => retroperitoneal hematoma
passes into abdominal cavity
J.K. Bryceland, Injury, Int. J. Care Injured 2008

 31 in 80 unstable pelvic Fx patients with free

fluid and undervent laparotomy
 1 in 31 patient show retroperitoneal
hemaotoma alone
 Mortality rate 35% in laparotomy group
Steffen R, J Trauma.2004;57:278 –286.
Unstable

Trauma Mattox Edition6

Secondary brain injury
- Hypovolemic shock
- Polycompartment syndrome

Severe HI associated DIC

- Now, conservative in solid organ injury is
accept
- Threshold for laparotomy lower than non HI
Trauma Mattox Edition6

Laparotomy or CT head first ??

Laparotomy in patient with GCS 2T ??
Trauma Mattox Edition6
Technique for temporary
control of hemorrhage
Perihepatic packing
Electrocautery or argon beam
coagulator
Pringle’s manoeuvre
Hemostatis agent and glues
Hepatic suture -> large curve needle
Chromic
Technique for temporary
control of hemorrhage
Finger fracture hepatotomy and
vessel ligation
Tract temponade balloon
(Sengstaken tube)
Tractotomy and direct suture
Mesh wrap
Hepatic artery ligation
Technique for temporary
control of hemorrhage
Hepatic resection
Hepatic vascular isolation
Atriocaval shunt
Veno-venous bypass
Hepatic vascular isolation
 Pringle’s
manoeuvre
 Clamp IVC above Rt kidney (Suprarenal)
 Clamp IVC above live (Suprahepatic)
Atriocaval shunt
 Good exposure
 Proximal and distal control
 Anatomical distortion from hematoma

 Activebleeding
- Pressure first
- Supraceliac control or Lt anterolateral
thoracotomy in aorta injury
- Supradiaphragmatic control in IVC

Manual of Definitive Surgical

Trauma Care, Boffard
 Retroperitoneal organ
 In early of injury, abdominal exam is difficult

 FAST or DPL maybe negative

 Retorperitoneal free air in plain film
or CT)

 High mortality if delay diagnosis

 Shouldbe Kocherization and open lesser sac

in blunt abdominal injury
Duodenal Inj

Trauma Mattox Edition6

 Pancreatic Inj

Trauma Mattox Edition6

Non-operative
Indication for surgery follow non-operative
 Hemodynamic instable
 Evidence of continued splenic hemorrhage
 Associate intra-abdominal injury requiring
surgery
 Replacement of more than 50% of blood
volume
Spleen not active bleeding
-> left alone

Splenic surface bleeding only

-> packing, diathemy or fibril glue

Minor lacerations
-> absorbable suture use pledget,
omental patch may be place
Splenic tears
1) Mesh wrap -> absorbable mesh e.g. Vicryl
wrap from hilum and around parenchyma

2) Partial splenectomy -> ligating segmental

vessel at hilum and seen demarcation
ischemic pole

3) Splenectomy
Option Depend on
 Primary repair  Position of injury
 Resection => Stomach, Small
+/- anastomosis bowel, Colon
 Severity of injury
+/- proximal
diversion  Contamination

 Diversion only  Patient status

Can not conservative

Need to Laparotomy
 Aim of trauma is patient survive
 Different resource => different judgment
 Now, try conservative but patient safety is
most important
 Don’t forget call for help
 Damage control if indication