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ABDOMINAL

INJURIES
Prof.Dr. Turgut PEK

Resuscitation and Evaluation

Resuscitation

Evaluation of the Patient with Blunt Trauma

Evaluation of the Patient with Penetrating Trauma

Treatment

Abdominal wall injuries

iver injuries

!"lenic injuries

Biliar# tract injuries

Pancreatic injuries

$astrointestinal tract injuries

$enitourinar# tract

%njuries of to the male genitalia

&terine injuries

&rethral injuries

Bladder injuries

Kidne# injuries
Resuscitation and Evaluation
1
Resuscitation
'. Does the "atient need an abdominal o"eration(
). *ill the "atient tolerate the time re+uired for
diagnostic maneuvers before surger# is
"erformed(
Resuscitation and Evaluation
2

Airwa# maneuvers

Endotracheal intubation

Tube thoracostom# ,"neumothora-. hemothora-/

0irculation

%1 lines ,u""er e-tremit#. nec2. thoracic inlet/


,jugular. subclavian catheter/

3asogastric tubes ,blood/

Bladder catheteri4ation

Tetanus to-oid. antibiotics


Evaluation o t!e "atient #it!
Blunt Trauma
1
Difficult5
'. 6ulti"le injuries ,head. e-tremities. thora-/
). Acute alcoholic 7 into-ication. drug abuse
8. !olid organs bleeds slowl#
Evaluation o t!e "atient #it!
Blunt Trauma
2
$linical Maniestations

A careful histor#

Ph#sical e-amination

9#"otension or "eritonitis

%ns"ection
:ractures in the lower si- ribs(
0ontusion over the lower chest(
!us"ect5 iver or !"leen injur#

Pal"ation
Peritonitis ,involuntar# guarding. rigidit#. rebound
tenderness/
Evaluation o t!e "atient #it!
Blunt Trauma
%
Dia&nostic "rocedures
Radiologic :indings

Plain ;<ra# ,:ree air bubbles in the ru+/

0hest ;<ra#

$ross hematuria 5 %1P

Retrograde c#stogra"h# ,blood at the meatus/


E'amination and O(servation
:alse 7 ,= >8/
:alse ? ,= )'/
Evaluation o t!e "atient #it!
Blunt Trauma
)

D%A$3@!T%0 PER%T@3EA TAPAA1A$E


,DP/
Indications

Altered sensorium from a head injur#. drug ingestion. or


alcohol into-ication

Altered sensation from a s"inal cord injur#

Rib or vertebrae fractures

E+uivocal findings on "h#sical e-amination


Relative $ontrindications

Abdominal scars

atter stages of "regnanc#

6orbid obesit#

0oagulo"ath#
Evaluation o t!e "atient #it!
Blunt Trauma
*
Dia&nostic "eritoneal Ta+,Lava&e -D"L.

ocal anesthesia. )<8 cm vertical midline incision.


8<> cm below the umblicus

)B ml gross blood. feces. bile. food. intestinal fluid


,7/

'BBB ml normal saline ,'B7'C mlA2g child/

RB0 D 'BB.BBB Amm8


*B0D CBB A mm8 7 DP
$ram stain

)> h observation and re"eated e-aminations


Evaluation o t!e "atient #it!
Blunt Trauma
/
Ultrasound

iver. s"leen. "ancreas and 2idne# injuries


$T
'. !table "atients with closed head injur#
). !table "atients with an e+uivocal abd. e-a.
8. Patients with hematuria
>. Pelvic fractures

Retro"eritoneal structures ,"ancreas. 2idne#/


Arterio&ra+!0
La+arosco+0
Evaluation o t!e "atient #it!
"enetratin& Trauma
$linical Maniestations

9ow did it ha""en( ,the tract/

Ph#sical e-amination

9#"otension. distension. "eritonitis hematemesis. "roctorrhagia.


hematuria
Dia&nostic "rocedures
Radiologic :indings
Plain ;<ra# ,free air. missile/
%1P
@bservation
DP ,anterior abdomen. lower chest or flan2s/
tangential gunshot wounds
Sta( 1ounds

ocal wound e-"loration and DP and e-aminations

Bac2 wounds ,colon(. observation/


contranst<enhanced 0T enema
2uns!ot 1ound
Automatic la"arotom#
Tangential ,observation or DP/
S!ot&un 1ound
Peritoneal "enetration b# "ellets( @bservation
ateral ;<ra#
3re4uenc0 o Or&an In5ur0 in
Blunt ABD Trauma
:re+uenc# = :re+uenc# =
@rgan injured Admission 0eliotom#
!"leen CE.) CE.E
iver >F.F >>.F
0olon ').G '>
!mall Bowel ').) '>
Kidne# H.C G.>
Pancreas F F.)
Duodenum C.> F
Bladder >.8 8.G
3re4uenc0 o Or&an In5ur0 in
Sta( 1ounds o t!e ABD
Or&an in5ured 3re4uenc0 -6.
iver 8H.8
!mall bowel 8'.F
Dia"hragm 'H.F
0olon 'C.8
!tomach ').F
6ajor vascular 'B.8
Kidne# H
!"leen E
Pancreas F
$allbladder ).8
Duodenum '.F
3re4uenc0 o Or&an In5ur0 in
2uns!ot 1ounds o t!e ABD
Or&an in5ured 3re4uenc0 -6.
!mall bowel >H.8
0olon >'.F
iver )H.8
1ascular )>.F
!tomach 'E.8
Kidne# 'E
Duodenum ''
Dia"hragm 'B
!"leen E.F
Bladder E.8
$allbladder E
Pancreas F
Rectum 8.8
@ther >
Liver In5uries
1

The most commonl# injured organ


Mec!anism o In5ur0

Direct blows. comression or shearing


$linical Maniestations

Profound h#"otension

6ar2ed abdominal distension


D"L7 $T
Liver In5uries
2
Treatment
3ono"erative A""roach
8. !im"le he"atic "arench#mal laceration or intrahe"atic
hematoma
>. 3o evidence of active bleeding
C. %ntra"eritoneal blood loss I )CB ml
F. Absence of other intra"eritoneal injuries re+uiring
o"eration
Su(ca+sular or Intra!e+atic 8ematoma
Nono+erative mana&ement -(ed rest7 n(m7 anti(iotics.
Liver In5uries
%
$eneral Princi"les of o"eration
Pringle 6aneuver ,0lam"ing of "orta he"atis 'B<'C minute is
recommended but 8B mn. is acce"table/
6obili4ation of obe
0om"ression. To"ical Agents ,!urgical. !"ongostan/
:ibrin $lue
!uture 9e"atorrha"h#
9e"atotom# with !elective 1ascular igation
@mental Pac2
Resectional Debridement with !elctive 1ascular igation
Resection
!elective 9e"atic Arter# igation
Perihe"atic Pac2ing
Liver In5uries
)
$om+lications
9emorrhageA9emobilia
%ntraabdominal Abscess
9#"er"#re-ia
Biliar# :istulae
S+leen
1
Incidence

The most commonl# injured organ in blunt


abdominal trauma
Mec!anism o In5ur0

Deceleration<t#"e trauma causes ca"sular


tears
S+leen
2
Dia&nosis
0linical 6anifestations

9#"otension ,'A8/

KehrJs !ign5 "ain at the ti" of the left shoulder


in the head down "osition ,= CB/

eu2oc#tosis ,D 'C.BBB/
S+leen
%
Radiolo&ic 3indin&s
). Elevation of the left hemidia"hragm
8. Enlargement of the s"lenic shadow
>. 6edial dis"lacement of the gastric bubble
C. *idening of the s"ace between s"lenic
fle-ure and the "re"eritoneal fat "ad
S+leen
)
$T

E-tremel# useful both in detection and fallowing the


healing
Treatment
%m"ortance of the !"leen

%mmunologic im"ortance. The ris2 of se"ticemias


from enca"sulated microorganisms ,"neumococcus.
meningococcus. and hemo"lhilus/ in the first ) #ears
after s"lenectom#.
@P!% ,@verwhelming "osts"lenectom# infection/
mortalit# 8B =
S+leen
*
3ono"erative A""roach
'. 3o hemod#namic instabilit#
). 3o "eritoneal findings
8. 3o need more than ) units of blood
!"lenectom#
!"lenorrh"#
Partial s"lenectom#

Resuscitation and Evaluation

Resuscitation

Evaluation of the Patient with Blunt Trauma

Evaluation of the Patient with Penetrating Trauma

Treatment

Abdominal wall injuries

iver injuries

!"lenic injuries

Biliar# tract injuries

Pancreatic injuries

$astrointestinal tract injuries

$enitourinar# tract

%njuries of to the male genitalia

&terine injuries

&rethral injuries

Bladder injuries

Kidne# injuries