TRAUMA

TUMPUL
ABDOMEN
STASE BEDAH DIGESTIF JANUARI 2019
ANATOMI ABDOMEN
Abdomen internal
Retroperitoneal Zone
Organ intra abdomen

 Letak
- Intra peritoneal
- Retro peritoneal
 Isi organ
- Organ solid
- Organ berongga
MECHANISM OF INJURY
BLUNT
 COMPRESSION/ CRUSHING
 SHEARING (seat belt improperly worn)
 Fixed organ injury
 ORGAN INJURY:
 Liver
 Spleen
 Hollow viscus
 Retroperitoneal
 TANPA SEATBELTS & TANPA BALON
Fase 3 AGD

20
Indication for Objective Evaluation
in Blunt Abdominal Trauma.
Riwayat Penyakit (RPS)
 Mekanisme trauma : prediksi organ dan tingkat kerusakan
 Macam kendaraan
 Tempat/ dimana kecelakaan
 Trauma tumpul
 Posisi penderita/ duduk
 Seat belt, head rest dll
 Pertolongan awal
History/ RPS

Blunt
 Speed
 Point of impact
 Intrusion
 Safety devices
 Position
 Ejection
 Assessment: Physical Exam
 Inspection, auscultation,
percussion, palpation
 Inspection: abrasions,
contusions, lacerations,
deformity
 Auscultation: careful exam
advised by ATLS.
(Controversial utility in trauma
setting.)
 Percussion: subtle signs of
peritonitis; tympany in gastric
dilatation or free air; dullness
with hemoperitoneum
 Palpation: elicit superficial,
deep, or rebound tenderness;
involuntary muscle guarding
• DRE (digital rectal examination)
Manifestasi klinis trauma abdomen

1. Perdarahan intra-peritoneal
* gejala dan tanda syok
* gejala dan tanda
darah dalam rongga peritoneum
- nyeri dan nyeri tekan
- mungkin distensi
- tanda adanya darah dalam
rongga abdomen (fisik,DPL,USG)
Manifestasi klinis trauma abdomen
2. Peritonitis

* karena pecahnya organ

ber-lumen
* gejala dan tanda
peritonitis
PEMERIKSAAN BANTUAN

 FAST
 DPL
 MSCT abdomen
 Laparoskopi diagnostik
 Explorasi luka
 TEHNIK KHUSUS UNTUK MEMBANTU
DIAGNOSTIK TRAUMA ABDOMEN
KEUNTUNGAN KERUGIAN

Pem.Klinik Cepat, noninvasif Meragukan (subjektif)

DPL Cepat, tidak mahal Invasif, terlalu sensitif,

spesifiknya terbatas
FAST Cepat, Noninvasif Tergantung operator

CT-SCAN Organ specific, informasi Pasien harus stabil,

retroperitoneal mahal
LAPAROSKOPI Organ specific Nyeri, perlu narkose
DIAGNOSTIK umum
FAST
 Europe  U.S.
 Speed & convenience; noninvasive, costly
 Detection of ‘hemoperitoneum’ at 4 areas,
sensitivity 90%(75-95%), at least 300 ml
 High degree operator dependency
 Lack of sensitivity for subtle injuries
 Role in intraoperative evaluation,
eq.thrombosis.
INDICATION :
- Hemodinamically unstable w/o obvious indication for laparotomy
- Requiring prompt transfer to OT for non abdominal cause
- Screening test for all others requiring abdominal evaluation
CONTRAINDICATION :
Obvious need for laparotomy / lack of FAST expertise
 Focused Assisted
Sonography for Trauma
(FAST)
ADVANTAGE DISADVANTAGE  Operator dependence
 Diagnose intra-abdominal  Poor evaluation for hollow
fluid with a sensitivity of viscous and retroperitoneal
96% and an accuracy of injury
99%.
 Cannot detect diaphragm
 Can detect Cardiac
rupture
Tamponed
 Can be done in
Emergency Room (patient
unstable)
 Easy to use Negative FAST  serial exams
 Repeatable for 6 hours and repeat FAST or
abdominal CT, depending on
 No radiologic exposure
Rose JS. Ultrasound in abdominal trauma. Emerg the clinical scenario
Med Clin N Am. 2004
 FAST RESULT

FLUID IN HEPATORENAL FLUID IN

INTERFACE PERICARDIAL SPACE

FLUID IN PELVIC FLUID IN PERICOLIC FLUID IN SPLENORENAL

SPACE GUTTER INTERFACE
DPL
 1965 by Root et al
 Seldinger / open / semi-open
 Very rapid test
 Lack of specificity : blunt, minor injury,
retroperitoneal & diaphragmatic injury
 Value in patients being taken to OT for
treatment of extraabdominal injuries
 Accuracy : sensitivity & specificity 95%, false
negative 4%. Non therapeutic rate 15-27%
INDICATION = FAST
CONTRAINDICATIONS : need laparotomy,
RELATIVE : previous abdominal op,
pregnancy & pelvic fracture
DPL: Diagnostic Peritoneal
Lavage
 Advantage
High Sensitivity and specificity Disadvantage
to detect blood  Invasive
 My detect hollow viscous injury  Poor evaluation for
through detection of its retroperitoneal
content  Can not detect
diaphragm injury
 Can not detect the
source of bleeding
 Unreliable for previous
operation (due to
adhesion)
 Relative contra indication
FAST IS NOW MOST for pregnant
PREFERABLE
 Diagnostic Peritoneal
Lavage
 Dekompresi buli dengan kateter urin
 Dekompresi lambung dengan NGT
 Asepsis dan antisepsis
 Injeksi lidocain di midline tepoat dibawah
umbilicus. Sebaiknya gunakan lidocain dengan
campuran epinephrin untuk mencegah
kontaminasi darah pada DPL
 Insisi vertikal pada kulit, sampai dengan fascia
 Jepit tepi fascia dengan clamp dan angkat. Buka
fascia sampai dengan peritoneum
 Masukkan kateter ke dalam cavum abdomen
 Arahkan kateter ke dalam cavum pelvis
Sumber : ATLS. 2008
  Hubungkan kateter dengan syringe. Aspirasi
 Jika tidak didapatkan darah. Masukkan 1 liter
cairan Nacl fisiologis (10 cc/kg untuk anak anak)
 Secara gentle aduk /miring miringkan abdomen
untuk mencampur darah dengan cairan
 Jika kondisi pasien stabil, biarkan cairan tetap
berada dalam cavum abdomen selama
beberapa menit, kemudian hubungkan dengan
kantung yang ada di lantai. Keluar cairan yang
adekuat adalah jika keluar > 30 % volume cairan
infus yang dimasukkan

Sumber : ATLS 2008

 Setelah cairan keluar, segera kirim ke
laboratorium untuk pengecatan gram
penghitungan eritrosit dan leukosit
 Hasil DPL Positif dan membutuhkan
intervensi bedah adalah jika eritrosit >
100.000 mm3, leukosit > 500 /mm3, dan
pengecatan gram positif untuk bakteri
dan serat makanan.

Sumber : ATLS 2008

Sumber : Schwartz’s Principles of Surgery. Tenth edition. 2015
CT scan
 Late 1970s by Federle & Trunkey.

 High degree of sensitivity & specificity in staging solid organ injuries.

Accuracy : 92-98%.

 Poor sensitivity for blunt intestinal injury (small amounts of free

intraperitoneal fluid: 100-200 ml)

 Diagnoses : retroperitoneal hematoma & associated injuries (chest &

bony pelvis)

 Need time for transportation (hemodynamically stable), expertise of

experienced radiologic personnel & surgeons, Cost, IV / triple contrast

 False negative 1.6% & false positive 3.2%.

 Late scanning : bowel rupture, pancreas fractures & necrosis

INDICATIONS : hemodinamically stable

CONTRAINDICATION : unstable / need laparotomy

DIAGNOSTIC LAPAROSCOPY (DL)
IN PENETRATING ABDOMINAL
WOUND
RECOMMENDATION

Diagnostic laparoscopy may be

considered as a tool to evaluate
diaphragmatic lacerations and
peritoneal penetration.
Laparoscopy
 Specificity is good, but low
sensitivity for hollow viscous,
retroperitoneal & blunt trauma
 Advised for penetrating trauma,
tangential GSW
 More complex : sensitivity, cost,
time & personnel requirements
 Potential for therapeutic for solid
organ & diaphragm injuries.
 Kerangka Penanganan
1. Preparasi
2. Triase
3. PS (ABC’s), k/p resusitasi dan px tambahan
4. SS (History/ RPS & Head to Toe Evaluation) dan px tambahan
5. Pengawasan pasca resusitasi dan re-evaluasi
6. Penanganan definitif
Management Strategy: Avoid
Second hit
 EGDT
 Treat abdominal compartment syndrome
 Judicious use of fluid resuscitation and blood
transfusion.
 Pain killer (analgesia)
 Prevent infection
 Prevent surgical complications to minimize the
requirement of secondary operation.
Resusitasi

 Problem trauma abdomen yang “life tretening”

adalah perdarahan
 ! IV-line ganda dan cairan RL hangat
 Menghentikan perdarahan segera, tms
Laparatomy, merupakan bagian dari resusitasi
Assessment of Resuscitation

 Vital Signs : BP (≥ 110 mmHg), RR

 Pulse: Rate, Strength
 Skin Color + Temperature
 Capillary Refilling Time
 Urine Output (0,5 ml/KgBW/hr)
 End point for hypotensive resuscitation:
1. Penetrating trauma – 80-90 mm Hg, / presence of radial
pulse.
2. Blunt trauma – 80-90 mm Hg, or presence of radial pulse.
3. Head injury – 100 mm Hg.
 Algoritma Trauma Tumpul
Abdomen

Sumber : Schwartz’s Principles of Surgery. Tenth edition. 2015

Trauma
Laparotomy
Incision
Perihepatic Packing
Splenectomy
Pemeriksaan usus
Kocher-Cattel Braasch
Maneuver
Mattox Maneuver
Pelvic Packing
Damage Control
Abdominal Closure
TERIMA KASIH