ABDOMINAL TRAUMA

dari aceh sampe merauke

FHA

FHA
PHYLOSOPHY TRAUMA
• The approach cannot be routine “take a history, do an exam, order
some test, make a diagnosis then threat the patient”
• Ex Chest tube  X-Ray
• The Management of the trauma victim “Should not be viewed as a
linear flow chart”
• When the physician is confident that the patient is stable and
adequately monitored  performs a full patient assessment
(Secondary Survey)

FHA
MAIN CONCEPT

FHA
 TRAUMA TUMPUL ABDOMEN
Dugaan Trauma Abdomen
Primary Survey (CXR – PXR) ABCDE
Temukan bahaya perdarahan
Hentikan kehilangan darah eksterna
Mulai resusitasi cairan
Hemodinamik stabil Hemodinamik tidak stabil

PE normal Prediksi perlukaan Abdomen PE tidak bisa dipercaya Konsultasi Bedah

(2nd survey) GCS < 15 PE tidak ragu
Nyeri / tender abdomen Intubasi Peritonitis
Fraktur pelvis / femur Intoksikasi Hemoperitoneum FAST DPL
Observasi hebat
Seatbelt signs/handle bar mark Anestesia
Fraktur kosta bawah SCI + gangguan saraf Cairan bebas + Aspirasi darah > 10 ml
Nyeri tender tepi kosta PTX RBC > 100.000/mm3
Hematokrit < 30% WBC 500/mm3
Hematuria Laparotomy Sisa makanan
SGOT meningkat Empedu
EFAST posistif
Konsultasi Tidak Ya Ya Tidak
Bedah

CT-scan Laparotomi
± kontras eksplorasi
Atau FAST / DPL
Secondary survey Secondary survey
Resusitasi lanjut Resusitasi lanjut
Selective management Evaluasi penyebab Evaluasi penyebab
lain syok lain syok
Interventional Radiology Laparotomy Ulang FAST FAST
DPL Ulang DPL
FHA
 HEMORRHAGIC SHOCK
Injury Primary Survey – ABCDE
Blood type – Cross Match

SI Hemodynamic Unstable Hemodynamic Stable

Crystaloid (Ringer Acetate) 2L Bollus Ballanced Fluid Therapy Diagnostic and Priorities PE – Lab - USG
→ Urine output 0,5 ml/kg/hour
Fail to responds ( > 40% blood loss)
Responds Remain Stable
HR > 120/min EIDT – Code Hb > 7 grm / dl
Red On Going
Remain Stable BP < 90 mm Hg
Hb > 7-8 grm / dl hemmorhage Treat accordingly
On going hemmorhage
MAP > 65 DSTC
Transfer
Transient Responds (15% - 40% blood loss) - DCR -
Treat accordingly
On going hemmorhage Coagulopathy
Permissive hypotension
TICCS
Syst 80 - 90 mm hg
MAP 50 – 60 mm hg Transfuse Blood / pRBC TASH Score + Tranexamic acid
M.T – score / MT Protocol Basedeficit lactate Ballanced Transfusion
Laboratory – Clinical – Diagnostic PT – PTT - Platelet pRBC : plasma : platelet 1 : 1 : 1

Responds No Responds
SI : Shock Index
EIDT : Early Individual Directed Therapy
DCR : Damage Control Resuscitation Treat accordingly Control Bleeding
DCS : Damage Control Surgery - Surgical DCS
DSTC : Definitive Surgical Trauma Care - Embolization
MT : Massive Transfusion
FHA
Trauma Tajam

Biffl, W. L. and Leppaniemi, A. (2015) ‘Management guidelines for penetrating abdominal trauma’,
FHAPresentations from the 9th Annual Electric Utilities Environmental Conference, 39(6), pp. 1373–
1380. doi: 10.1007/s00268-014-2793-7.
Trauma Tajam

Biffl, W. L. and Leppaniemi, A. (2015) ‘Management guidelines for penetrating abdominal trauma’,
FHAPresentations from the 9th Annual Electric Utilities Environmental Conference, 39(6), pp. 1373–
1380. doi: 10.1007/s00268-014-2793-7.
COLORECTAL TRAUMA

FHA
 Colorectal Trauma – Etiology
COLON RECTUM
• Penetrating • Penetrating
• >85% • Majority
• 1/3 penetrating abdominal • GSW
injuries • Impalement / straddle injuries
• GSW > SW > shotgun > iatrogenic • Iatrogenic
> misc • Foreign body

• Blunt • Blunt
• MVA, ped struck, falls • Pelvic fractures
• Multiple injuries • Disruption of pubic symphysis
• Delayed presentation • Spicules

• Scrape injuries
• Drag over pavement s/p
• motorcycle accident

• Trauma to perineum - High index suspicion

FHA
 Classification

Destructive vs.
Nondestructive
wounds

Feliciano David, Mattox. Trauma 7 th ed, 2013 FHA

 TRAUMA : COLO-RECTAL INJURY

• Nondestructive injuries include those involving less than 50% of the

bowel wall and without devascularization (Gr II) Primary Repair

FHA
Michael J. Zinner, Stanley W. Ashley. Maingot’s Abdominal Operation . 12TH edition, McGraw-Hill Education, 2017.
TRAUMA : COLO-RECTAL INJURY
Fabian and Stone Criteria for Obligatory
Colostomy

Stone, H. H. and Fabian, T. C. (1979) ‘Management of perforating colon trauma. Randomization between primary closure and
exteriorization’, Annals of Surgery, 190(4), pp. 430–436.
Coleman, J. J. and Zarzaur, B. L. (2017) ‘Surgical Management of Abdominal Trauma’, Surgical Clinics of North America, 97(5),
pp. 1107–1117. FHA
 Management of Colon Injuries
• Non Destructive Wounds
• loss of less than 50% of the bowel wall and without devascularization
• Primary repair or resection + anastomosis

• Destructive wounds
• loss of more than 50% of the bowel wall circumference or with devascularization
• Patients at risk for anastomotic breakdown
• Immunocompromised patients
• Transfusion >6 units
• Likely increased
• Shock
• Delay of operation
• Traditionally  diverting colostomy
• New data  resection + primary anastomosis
One strict contraindication, delay > 12 hours
FHA
Management of Colon Injuries

Diversion Resection + Anastomosis

FHA
 management of Colon Trauma
Colectomy?

YES NO

High Risk No
Factors? * Colectomy
YES NO

Primary
Primary Primary
repair or
repair repair
Colostomy

* Damage control op, blood transfusion >6 units, multiple associated abdominal injuries,
FHA
severe bowel edema, suboptimal vascular supply to resected margins
 Suspicion of Rectal Trauma

Abdominal Exam w/ DRE

Unremarkable Exam Probable injury Peritonitis

(Rectal bleeding, obvious defect, etc) Hemodynamic Instability

CT +/- rectal contrast Laparotomy

Positive r/o intra-abdominal injury
Negative
Evaluate for
Observe extraperitoneal injury
Proctoscopy in OR

Extraperitoneal Intraperitoneal
Rectal Injury Rectal Injury

Non destructive Destructive (>25% Circumference) Non destructive Destructive

(<25% Circumference) Or associated pelvic fracture (<25% Circumference) (>25% Circumference)

Accessible Transanally ? Fecal Diversion

Hartmann for severe destruction Primary Repair Resection and
anastomosis

Transanal repair Communicate w/ presacral space ?

No Yes

Admit for observation Consider distal washout Consider presacral drainage &
Consider barium for high velocity/blast consider distal washout for
enema in 5-10 days injuries high velocity/blast injuries
FHAClemens MS, Peace KM, Yi F. Clin Col Rect Surg 2018; 31 : 17 – 23
Management of Intraperitoneal Rectal
Injury
Patient present with rectal injury

Wound in non destructive Wound in destructive

Partial thickness : perform
seromuscular closure
Full thickness : repair with
primary closure
Look for risk factors
intraoperative infusion > 6 U
underlying comorbid conditions
delayed operation, shock

No risk factor are present Risk Factor present

Repair with resection and Perform resection with end
primary anastomosis colostomy
Or
Perform resection and primary
anastomosis with proximal
dissection

FHA
Feliciano D, Mattox K, Moore E. Trauma. McGraw-Hill. 2008
Management of Extraperitoneal Rectal
Injury

Feliciano D,
FHAMattox K, Moore E. Trauma. USA: McGraw-Hill Co, Inc., 2008.
FHA
LIVER TRAUMA

FHA
Anatomy
• Largest solid organ in the human
body
• Blood supply of 1,500 ml/min
and complex vascular anatomy
• Relatively inaccessible anatomic
location

FHA
Mechanism of Injury
• Blunt
• Motor vehicle accidents 80%
• Thoracic trauma is most common associated injury
• Head injury is the most significant determinant in overall mortality.
• Penetrating
• Thoracoabdominal penetrating injury is associated with liver injury in 40%
• Require surgery more often than blunt injuries

FHA
Mechanism of Injury – Blunt Trauma
Acceleration
Deceleration Crush
Right Front Left

FHA
Gr Injury 1989 1994
I Haematoma Subcapsular, nonexpanding, <10% surface area Subcapsular, <10% surface area

Laceration Capsular tera, nonbleeding, <1cm parenchymal Capsular tear <1 cm parenchymal depth
depth
II Haematoma Subcapsular, nonexpanding, 10-50% surface area Subcapsular, 10-50% surface area
Intraparenchymal, nonexpanding, <2cm in diameter Intraparenchymal, <10 cm diameter
Laceration Capsular tear, active bleeding; 1-3cm parinchymal Capsular tears 1-3 cm parenchymal depth, <10 cm in
depth, <10cm in length length
III Haematoma Subcapsular, >50% surface area or expanding; Subcapsular, >50% surface area of ruptured
Ruptured subcapsular hematoma with active subcapsular or parenchymal/intraparenchymal
bleeding; haematoma
Intraparenchymal hematoma >2cm or expanding
Laceration >3cm parenchymal depth Parenchymal depth 3 cm
IV Hematoma Ruptured intraparenchymal with active bleeding
Laceration Parenchymal disruption involving 25-50% of hepatic Parenchymal disruption involving 25-75% of the
lobe hepatic lobe or >3 Couinaud segments
V Laceration Parenchymal disruption involving >50% of hepatic Parenchymal disruption involving >75% of the hepatic
lobe lobe or >3 Couinaud segments within a single lobe
Vascular Juxtahepatic venous injuries; i.e., retrohepatic Juxtahepatic venous injuries, e.g. retrohepatic vena
cava/major hepatic vein cava/central major hepatic veins
VI Vascular Hepatic avulsion Hepatic avulsion

FHA
Key principles in the management of
Hepatic Parenchymal Injury
1. Thorough knowledge of hepatic anatomy
2. Adequate exposure
3. The most experienced second pair of hands available at your
hospital
4. Good anesthesia support
5. Adequate supradiaphragmatic IV access and a rapid infusion device
6. Being a minimalist - do the minimal that fails the best

FHA
J Trauma Acute Care Surg 73, 3 (2012)
Before you start..
• Massive transfusion protocol
• Avoid hypothermia
• Avoid excessive crystalloid resuscitation
• Get prepared for another blood loss and exsanguination

FHA
Basic Operative Approach
Diagnostic & Therapeutic Maneuvres
 Bimanual compression of the liver
 Temporary pack
• Control other bleeding sources
• Manage hollow-viscus injuries

...then wait
until the anaesthetist has adequately
replenished the intravascular volume and
stabilized the blood pressure

BJSurgery 1999, 86, 1121-1135 FHA

Basic Operative Approach
Diagnostic & Therapeutic Maneuvres
• Bleeding not controlled by packing alone
suggests a complex hepatic injury
• Pringle maneuver (1908)
• Hepatic arterial bleeding
• Portal venous bleeding
• May use safely for up to 60-75 minutes
• If bleeding continue
• Retrohepatic IVC
• Major hepatic veins
J Trauma. 2011;71: 1–5
FHA
BJS1999, 86, 1121-1135
Bleeding Controlled by Pringle Maneuvre
Hepatorrhaphy?
• 1896 Kousnetsoff and Pḛski
• Transfixing suture and a blunt-tipped needle
• 1898 Waring
• Purse-string suture
• 1900 Canac-Marquis
• Continous double layer mattress suture

FHA
Liver Packing
Who, When & How to Pack

1. Onset of triad of death

2. Extensive bilobar injuries
3. Large, expanding or ruptured hematomas
4. Failure of other maneuvers
5. Patient who require transfer to a level I trauma center
6. Juxtahepatic venous injuries

 Watch IVC with packing

 Remove < 72 hrs
FHA
Liver Packing
• Trade-off for the trauma surgeon
• very useful
• a foreign body in the abdomen
• the need for a reoperation for removal

• It is always better to have a patient with packs to come

and deal with on another day, than trying to stop the
bleeding with no success

• Do not place packs in the cracks within the liver because

this worsens the liver injury and exacerbates the bleeding.

British Journal of Surgery 1999, 86, 1121-1135

FHA
J Trauma Acute Care Surg 73, 3 (2012)
SPLEEN TRAUMA

FHA
POSITION

FHA
FHA
SPLENIC BLOOD SUPPLY

FHA
SPLENIC BLOOD SUPPLY
• The spleen receives its arterial
supply from the splenic artery,
the largest of the three
branches of the celiac trunk
• The accessory supply is from
the left gastroepiploic artery

FHA
SPLENIC BLOOD SUPPLY
• The splenic artery has a very
tortuous course and a unique
pattern of distribution in every
individual
• Distributed type (70% of cases)
• Magistral type (30% of cases)

FHA
SPLENIC BLOOD SUPPLY
• The splenic artery also has a
pancreatic branch (pancreatica
magna) that is worthy of note.
• Occlusion of this branch, most
often seen after splenic artery
embolization, can lead to
pancreatitis

FHA
INNERVATION
• The splenic nervous plexus is formed by branches of the celiac plexus,
left celiac ganglion, and right vagus
• Referred pain from the spleen is frequently localized in the central
epigastrium
• Rupture of the Spleen  Iritation of the diaphragm  signaled by
phrenic nerve  Kehr Sign

FHA
IN FACT :
• In children, it is large because it is necessary for both
reticuloendothelial function and production of red blood cells.
• As the child’s bone marrow matures, the spleen becomes relatively
less important and diminishes in size relative to the rest of the body
• The capsule in children is relatively thicker than it is in adults, and
there is some evidence that the parenchyma is firmer in consistency
in children than it is in adults
• Children are more often candidates for nonoperative management

FHA
FHA
Grading of Spleen Injury

FHA
 FHA
Coccolini et al. World Journal of Emergency Surgery (2017)
FHA
RESPIRATORY DISTRESS ???
• Respiratory Distress  Abdominal Distention  Diaphragma 
• World Society of Abdominal Compartment Syndrome (WSACS) 2004 –
2006 :
• IAP (Intra Abdominal Pressure)  Is the steady-state pressure concealed
within the Abdominal Cavity
• ACS (Abdominal Compartment Syndrome) is sustained IAP > 20 mmHg with
or without Abdominal Perfusion Pressure (APP) < 60 mmHg that is associated
with a new organ dysfunction / failure.

FHA
ABDOMINAL COMPARTMENT SYNDROME
(ACS)
• IAP  5-7 mmHg (N) , max 12 mmHg
• Intra Abdominal Hypertension (IAH)  IAP > 12 mmHg
• Abdominal Perfusion Pressure (APP)
• APP = MAP - IAP
• APP > or ≤ 60 mmHg  poor survival

FHA
DAMAGE
1. Cardiovasculer : Venous Return , Statis  DVT, Ventricular Contractility 
2. Pulmonary : Peak Inspiratory Mean Airway, Alveolar Barotrauma, Arterial
Hypoxemia Hipercarbia, Atelectasis – Edema, Intrapulmonary Shunt, Gas
transfer , Alveolar Dead Space 
3. Renal : Direct Pressure Vena Renalis , Renal Vasoconstriction  ec RAA
System
4. Gastrointestinal : Direct Pressure Mesenteric  Edema  Hipoperfusi 
Ischemia  ph Mucosa   translocation bacteria
5. Liver : Tidak mampu mengeluarkan laktat
6. CNS : IAP   ICP 

FHA
MANAGEMENT

FHA
FHA
FHA
FHA
ENDPOINT OF RESUSCITATION
• SBP, HR ? Urine Output ?
• Fluid resuscitation
• Close monitoring
• DO2 (Oxygen Delivery) = [1.39 × Hb × SaO2 + (0.003 × PaO2 )]× cardiac output
• Base Excess
• Reflect tissue hypoxia
• Correlates : degree of shock, O2 Dept, Changes of DO2, Response of Resuscitation
• Good Predictor of MOF and Survival
• Responds slowly to changes in intravascular volume
• Serum Lactate
• Total O2 Debt
• Degree of Hypoperfusion
• Thus, the severity of hemorrhagic shock

FHA
TERIMA KASIH

FHA