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Penetrating abdominal trauma 2

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by

Joyce Ngai

on 11 April 2014

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Transcript of Penetrating abdominal trauma 2

Penetrating abdominal trauma
Breach of tissue by foreign objects
Between lowest ribs and groin creases to the front and gluteal creases to the back
Occurs rarely in children
In the US, abdominal trauma makes up 8-10% paediatric trauma admission, 8-12% of which are penetrating injuries.
Mechanisms of injury
Stabbing
violence - stabbing, gunshot
accident - shpranel, impalement
animal bites
classification - energy/velocity
combination of blunt and penetrating trauma
wide spectrum of severity
Low velocity
Lacerating and cutting
Liver (40%)
Small bowel (30%)
Diaphragm (20%)
Colon (15%)
Gunshot
High velocity - energy exchange
Surface area, density, deceleration
Damage lateral to track by cavitation
Entrance and exit wounds - path of least resistance
Fragmentation, ricochet
Small bowel 50%, colon 40%, liver 30%, abdominal vascular structure 25%
Special consideration in children
Anatomy
Flatter diaphragm
Shallower pelvis
Thinner muscle wall
Comparatively larger solid organs
Associated thoracic injury
Physiology
Better compensatory mechanisms
Smaller circulating volume
Primary survey per trauma guideline
Airway and breathing - ensure no associated thoracic injury
Circulation - haemodynamic stability
Disability
Exposure - abdominal exam, assess wound, temperature control
Adjunct - CXR, NGT, urinary catheter
Types of presentation
Pulseless - major vascular injury
Haemodynamically unstable (non-responder/transient responder) - vascular and/or solid organ injury and/or haemorrhage elsewhere
Haemodynamically stable - hollow organ injury, retroperitoneal injury
Interventions
Local wound exploration/CT/laparotomy
APLS - penetrating abdominal trauma
ATLS - haemodynamic instability
gunshot wound
peritoneal irritation
fascial penetration
Actions
Anaesthetist
Resuscitation
Cross-match +/- massive transfusion
Broad spectrum antibiotics
Photograph, clean and cover wound
Tetanus booster
Mindful of psychological effect
Tetanus
2nd, 3rd, 4th months + pre-school - DTaP/IPV(polio)/Hib; school leaver - Td/IPV(polio)
Incomplete primary course - outstanding doses at monthly intervals
Earliest first booster one year after complete course; second booster at least five years apart.
250 units human tetanus immune globulin IM
Operative outcomes
Damage control, haemostasis/repair
Solid organ/bowel resection
Remove foreign body +/-fluoroscopy
Ensure logical number of wounds
Fascial closure
Wound debridement
Damage control surgery
Resuscitation - permissive hypotension, damage control haematology, early source control
Initial phase - control and temporary closure
Resuscitative phase - correct coagulopathy, acidosis and hypothermia
Definitive phase
Summary
Penetrating abdominal trauma in children is rare but serious.
Majority will require surgical intervention.
Pattern of injury depends on mechanism and management varies depending on organs involved.
Associated with significant morbidity.
References
Advanced Trauma Life Support for Doctors Student Course Manual (eighth edition)
Advanced Paediatric Life Support The Practical Approach (fifth edition)
http://www.trauma.org/archive/abdo/penetrating.html
Liver
Haemodynamically unstable
Organ Injury Scale (AAST) - prognosis, not management (Grades I-VI)
Advocates for conservative management in haemodynamically stable blunt trauma
Position anatomically
Pack
Pringle manoeuvre - 30-90 minutes
Small bowel and colon
Peritonitism
I - haematoma/partial thickness laceration (no perforation), II/III - </>50% circumferential laceration, IV - transection, V - devascularised
Assess full length, retroperitoneal injury
Contamination control, anastomosis/stoma, short bowel syndrone
Diaphragm
Herniation of intra-abdominal viscera
Ventilatory problem, indirect evaluation
Rule out intra-thoracic injury
I - contusion, II - laceration <2cm, III - laceration 2-10cm (+1 if bilateral)
IV - laceration >10cm with <25cm2 tissue loss
V - laceration with >25cm2 tissue loss
Abdominal vascular structures
Pulseless or haemodynamically unstable
Proximal and distal control
Restore physiology
Repair or ligate
Ligation may cause end-organ ischaemia
Injury to higher order vessels more significant
Abdominal examination
During primary survey if haemodynamically unstable and no obvious source of haemorrhage
Soft/rigid, peritonism, distension
Generalised/localised tenderness
Wound - number, position, type, blood loss, clean/dirty, depth
Post-operative care
Intensive/high dependency care
Nutrition
Course of antibiotics
Wound care
Abdominal compartment syndrome
Sequelae of procedure
Safeguarding issue?
Evaluation
Options
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