CURRICULUM VITAE (1)

NAMA

: dr. I Ketut Wiargitha, Sp.B(K) Trauma

TEMPAT, TANGGAL LAHIR

: Denpasar, 21 Juni 1960

AGAMA

: Hindu

STATUS PERKAWINAN

: Kawin

TELEPON

: 08123804989

EMAIL

: Kwiargitha@yahoo.co.id

ALAMAT

: Jl. Jayagiri IX No.2, Denpasar

JABATAN SAAT INI

Ka. Sub Divisi Trauma dan Bedah Emergency RSUP Sanglah

Denpasar
Ketua Program Studi Spesialis Bedah Umum

CURRICULUM VITAE (2)

Riwayat Pendidikan

PENDIDIKAN

NAMA SEKOLAH

TAHUN
IJASAH

SD

NEGERI XXI Denpasar

1972

SLUB

I Saraswati Denpasar

1976

SLUA

I Saraswati Denpasar

1980

Dokter Umum

Universitas Udayana

1987

PPDS Ilmu
Bedah

Universitas Udayana

1998

Kolegium Bedah / Surabaya

2009

Konsultan
Traumatologi
Bedah Akut

CURRICULUM VITAE (3)

RIWAYAT PELATIHAN

NAMA PELATIHAN

PELAKSANA
PELATIHAN

Pelatihan Advanced Trauma

Life Support (ATLS)

RS Sanglah Denpasar/IKABI

Pelatihan Advanced Trauma

Life Support (ATLS)

RS Sanglah Denpasar/IKABI

Pelatihan Advanced Trauma

Life Support (ATLS)

RS Sanglah Denpasar/IKABI

TAHUN
PELATIHAN
20-23 Februari 2009
19-21 Februari 2010
1-3 Oktober 2010

K3RS

DIKLAT/RSUP Sanglah
Denpasar

3 November 2011

BHD (Bantuan Hidup Dasar)

DIKLAT/RSUP Sanglah
Denpasar

20-21 April 2011

PPI

DIKLAT/RSUP Sanglah
Denpasar

10 Mei 2012

Komunikasi Efektif

DIKLAT/RSUP Sanglah
Denpasar

17 September 2015

TRAUMA TUMPUL ABDOMEN

dr I Ketut Wiargitha, SpB (K) Trauma

SEMINAR KEGAWATDARURATAN PADA KASUS BEDAH
27 MARET 2016

Objectives

Describe external and internal anatomy

Recognize blunt vs penetrating injury patterns
Identify signs of different types of injuries
Initial Assesment & Management
Apply diagnostic and therapeutic procedures

ANATOMY

EXTERNAL

Anterior
Superior : transnipple line
Inferior : inguinal ligaments and
symphysis pubis

Lateral : anterior axillary lines.

Flank
between the anterior and
posterior axillary lines from the
sixth intercostal space to the iliac
crest.
Back
This is the area located posterior
to the posterior axillary lines from
the tip of the scapulae to the
iliaccrests.

DEPAN

BELAKANG

ANATOMY
INTERNAL
Peritoneal Cavity
The upper peritoneal cavity :
diaphragm, liver, spleen,
stomach, and transverse colon.
The lower peritoneal cavity :
small bowel, parts of the
ascending and descending
colon, sigmoid colon, and, in
women, internal reproductive
organs.

ANATOMY
INTERNAL
Pelvic Cavity : rectum, bladder,
iliac vessels, and, in women,
internal reproductive organs.

Retroperitoneal Space :
abdominal aorta, inferior vena
cava, most of the duodenum, the
pancreas, kidneys and ureters,
and the posterior aspects of the
ascending and descending colon,
and the retroperitoneal
components of the pelvic cavity.

Mechanism of injury

Blunt

Spleen, liver, and hollow viscus

Compression
Crushing
Shearing
Deceleration (fixed organs)

Mechanism of injury
Penetrating
Liver , small bowel, and colon
Laceration / low energy
Kinetic energy / high energy

12

Blunt Abdominal Trauma

13

Penetrating Abdominal Trauma :

Stab Wound

Abdominal Evisceration

14

Penetrating Abdominal Trauma :

Gunshot Wound

15

Gunshot Wound (machine gun)

16

CLASSIFICATION
Based on the mechanism of injury :
Blunt Abdominal Trauma
compression
crushing or shearing injury
deceleration injury
Penetrating Abdominal Trauma

stab wounds
gunshot wounds

We will focus on Blunt Abdominal

Trauma

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INITIAL ASSESMENT
& MANAGEMENT

19

20

Primary
Survey

21

Monitoring :
Vital sign, ECG,CVP

Adjuncts to
Primary Survey

NG tube placement
Foley catheter placement

DPL, FAST
Radiograph
Laboratory examination

 History :

22

1. Allergies
2. Medication
3. Past illnesses or

Secondary
Survey

pregnancy
4. Last meal
5. Event related to the
injury
Mechanism of injury
Physical Examination

23

Spesific diagnostic
examination :
X-rays,

Adjuncts to
Secondary Survey

CT scans,

Urography,
Angiography,
USG,
Bronchoscopy,
Esophagoscopy,and etc

24

INITIAL MANAGEMENT
Begins with :

the rapid restoration of cardiopulmonary function

the priority is management of airway, breathing,
and circulation
Two most important diagnostic and therapeutic goals:
Rapid identification and control of major
hemorrhage
Identification and treatment of traumatic brain injury
(TBI)

25

HISTORY

Blunt Trauma (1)

Assessing the patient injured in a motor vehicular crash
includes :
speed of the vehicle,
type of collision (frontal impact, lateral impact,
sideswipe, rear impact, and rollover),
vehicle intrusion into the passenger compartment,
types of restraints,
deployment of an air bag,
the patients position in the vehicle, and
status of passengers

26

27

HISTORY

Blunt Trauma (2)

This information can be provided by :

the patient,
other passengers,
the police, or
emergency medical personnel.
Information about:
vital signs,
obvious injuries, and
response to prehospital treatment

28

PHYSICAL EXAMINATION

NO

FIND

1.

Inspection

abrasions, contusions from restraint devices,

lacerations, penetrating wounds,impaled
foreign bodies, evisceration of omentum or
small bowel, and the pregnant state

2.

Auscultation

confirm the presence or absence of bowel

sounds

3.

Percussion

signs of peritonitis, tympanitic sounds over an

acute gastric dilatation in the left upper
quadrant or diffuse dullness when a
hemoperitoneum is present

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PHYSICAL EXAMINATION

NO

FIND

4.

Palpation

to elicit and localize superficial (often abdominal wall), deep, or

rebound tenderness. The presence of a pregnant uterus, as well
as estimation of fetal age, also can be determined

5.

Evaluation
Penetrating
Trauma

Gunshot wounds 90% intraperitoneal injury laparotomy

Stab wounds 30% intraperitoneal injury laparotomy
any hemodynamically abnormal
signs of peritonitis or
mandates immediate
abdominal distention
laporotomy

6.

Assessing Pelvic abnormal movement or bony pain, which suggests a pelvic

Stability
fracture in patients who sustain blunt truncal trauma.

this maneuver may cause or aggravate bleeding.

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PHYSICAL EXAMINATION

NO

FIND

7.

Penile, perineal,
and rectal
examination

the urethral meatus : blood a urethral tear

scrotum and perineum : ecchymoses or a hematoma
rectal examination :
Blunt : assess sphincter tone, the position of the prostate
(high-riding prostate indicates urethral disruption), and to
determine whether fractures of the pelvic bones are present.

8.

Vaginal
Examination

Laceration of the vagina

31

INSERTION GASTRIC TUBE

Relieve acute gastric dilatation
Decompression of the stomach before performing
a DPL
Remove gastric contents
Reducing the risk of aspiration
If it found Blood (+) in the gastric secretions an
injury to the esophagus or upper gastrointestinal
tract if nasopharyngeal and/or oropharyngeal
sources are excluded.

32

INSERTION URINARY CATHETER

The goals of inserting this tube early in the
resuscitation process are :
Relieve retention
Decompression of the bladder before
performing a DPL
Monitoring of the urinary output as an index of
tissue perfusion

33

BLOOD AND URINE SAMPLING

Blood type and
crossmatch
Complete blood count
(CBC)
Electrolyte levels
BUN level

Creatinine level
Glucose level
Prothrombin time
(PT)/activated partial
thromboplastin time
(aPTT)

Venous or arterial
lactate level
Calcium, magnesium,
and phosphate levels
Urinalysis
Serum and urine
toxicology screen

A blood test or urine

pregnancy test is
indicated in all females
of childbearing age.

34

X-RAY STUDIES
BLUNT ABDOMINAL TRAUMA

Multisystem blunt trauma :

lateral cervical spine x-ray,
anteroposterior (AP) chest x-ray,
pelvic x-ray .

Hemodynamically normal :
Abdominal x-rays (supine, upright, or lateral decubitus) detect :
extraluminal air in the retroperitoneum
free air under the diaphragm
LAPAROTOMY
Retroperitoneal injury

loss of a psoas shadow

Special circumstance contrast studies : urethrography, sistography,

CT scan/IVP, gastrointestinal (CT with contrast or specific upper and
lower gastrointestinal contrast)

35

In the upright position, blood is visible dependently in the pleural space

36

DIAGNOSTIC STUDIES
DPL (Diagnostik Peritoneal Lavage)
FAST (Focused Assessment Sonography in Trauma)
CT (Computed Tomography)

37

DPL (Diagnostic Peritonial Lavage)

Indications for DPL in blunt trauma include:

1.

Change in sensoriumBrain injury, alcohol intoxication, and use

of illicit drugs

2.

Change in sensationInjury to spinal cord

3.

Injury to adjacent structuresLower ribs, pelvis, lumbar spine

4.

Equivocal physical examination

5.

Prolonged loss of contact with patient (anticipatedGeneral

anesthesia for extra abdominal injuries, lengthy x-ray studies, eg,
angiography (hemodynamically normal or abnormal patient))

6.

Lap-belt sign (abdominal wall contusion) with suspicion of bowel

injury

7.

DPL also is indicated in hemodynamically normal patients when

the same situations are present,but when ultrasound or CT is not
available.

38

DPL
Absolute contraindication:
an existing indication for laparotomy
Relative contraindications :
previous abdominal operations,

morbid obesity,
advanced cirrhosis, and
preexisting coagulopathy

39

DPL

Either an open or closed (Seldinger) infraumbilical technique

In patients with pelvic fractures or advanced pregnancy, an
open supraumbilical approach is preferred to avoid entering a
pelvic hematoma or damaging the enlarged uterus

40

DPL

RESULT :
free aspiration of blood,
gastrointestinal contents,

hemodynamically abnormal

vegetable fibers,or
bile through the lavage catheter

mandates laparotomy

If gross blood (>10 mL) or gastrointestinal contents are not aspirated,

lavage is performed with 1000 mL of warmed Ringers lactate solution
(10 mL/kg in a child) adequate mixing of peritoneal contents with
the lavage fluid sent to the laboratory for quantitative analysis
A positive test is indicated by :
>100,000 RBC/mm3,

500 WBC/mm3, or
a Gram stain with bacteria present.

41

FAST
Purpose is to identify fluid in one of four areas:
Morrison's (hepatorenal) pouch in the right upper
quadrant
The splenorenal recess in the left upper quadrant
The pelvis
The pericardial sac
The indications for the procedure are the same as for
DPL
Factors that compromise its utility are:
obesity,
the presence of subcutaneous air, and
previous abdominal operations.

42

FAST

at least 250 ml of fluid must be present

before it can be reliably detected by
FAST

43

FAST

Algorithm for the initial evaluation of a patient with suspected blunt

abdominal trauma. CT = computed tomography; DPA = diagnostic
peritoneal aspiration; FAST = focused abdominal sonography for
trauma; Hct = hematocrit.

44

CT-scan

Used only in hemodynamically normal patients in whom

there is no apparent indication for an emergency
laparotomy
The CT scan provides information relative to specific organ
injury and its extent, and also can diagnose retroperitoneal
and pelvic organ injuries that are difficult to assess by a
physical examination, FAST, or peritoneal lavage.
Relative contraindications to the use of CT include:
delay until the scanner is available,
an uncooperative patient who cannot be safely sedated,
an allergy to the contrast agent when nonionic contrast is
not available.

45

Blunt abdominal trauma with liver laceration.

46

Blunt abdominal trauma. Right kidney injury with blood in the

perirenal space. Injury resulted from a high-speed motor
vehicle collision.

47

DPL Versus FAST Versus CT

in Blunt Abdominal Trauma

48

DEFINITIVE MANAGEMENT

49

NON OPERATIVE MANAGEMENT

(CONSERVATIVE)
Stable hemodynamic
Observation and expectation
To prevent negative laparotomy
Example :
Liver Injury grade I, II, III, and spleen injury
grade I, II, III (hemodynamically normal, stop
bleeding)

Algorithm for the assessment of the patient

50
with blunt abdominal trauma

51

LAPAROTOMY
Acces & Exposure
Homeostasis Resection Reconstruction
Damage Control Surgery

52

INDICATIONS FOR LAPAROTOMY

IN ADULTS (1)
1.

Blunt abdominal trauma with hypotension and

clinical evidence of intraperitoneal bleeding

2.

Blunt abdominal trauma with positive DPL or

FAST

3.

Hypotension with penetrating abdominal wound

4.

Gunshot wounds traversing the peritoneal cavity

or visceral/vascular retroperitoneum

5.

Evisceration

53

INDICATIONS FOR LAPAROTOMY IN ADULTS (2)

6.

Bleeding from the stomach, rectum, or

genitourinary tract from penetrating trauma

7.

Presenting or subsequent peritonitis

8.

Free air, retroperitoneal air, or rupture of the

hemidiaphragm after blunt trauma

9.

Contrast-enhanced CT demonstrates ruptured

gastrointestinal tract, intraperitoneal bladder
injury, renal pedicle injury, or severe visceral
parenchymal injury after blunt or penetrating
trauma.

54

Postoperative and Postinjury Complications

1.

Missed Injuries

2.

Intra abdominal Compartment Syndrome (IACS)

severe intra abdominal injuries,
massive fluid resuscitation,

high abdominal wall tension,

and a variety of adverse physiological sequelae :
decreased urine output, high peak airway pressures,
compromised organ perfusion, has led to the
description of

55

IACS
IACS is produced by excessive intraabdominal
pressures as the result of massive bowel edema,
third space fluid, intraperitoneal
haemorrhage, or retroperitoneal hematomas.
decreases in splanchnic, renal, and abdominal
wall perfusion and may produce venous
capacitance pooling in the pelvis and lower
extremities from a tourniquet-like effect on the
mid torso

56

IACS

Measurement of intravesicular (bladder) pressure,

performed by :
instilling 50 to 100 ml fluid in the bladder and
measuring pressure via Foley catheter using either
manometry or a pressure transducer.
Pressure readings that are greater than 30 cm
H2O are consistent with IAC

57

IACS
The treatment of IACS has generally involved
Decompression of the abdominal compartment

Placement of a temporary abdominal wall

prosthesis.
In many instances,resolution of abdominal
compartment oedema allows either single or
staged closure of the abdominal wall

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SPECIFIC INJURIES

59

60

DIAPHRAGM
the left hemidiaphragm is more commonly injured.
The most common injury is 5 to 10 cm in length and
involves the posterolateral left hemidiaphragm.
Abnormalities on the initial chest x-ray include :
elevation or blurring of the hemidiaphragm,
a hemothorax,
an abnormal gas shadow that obscures the
hemidiaphragm,
or the gastric tube positioned in the chest.
However, the initial chest x-ray may be normal in a
small percentage of patients.

LIVER INJURIES
61

Principal therapeutic goals Control of hemorrhage, control/containment of biliary drainage.

Diagnosis/staging

CT staging preferred if possible for blunt injury. Selection for

nonoperative management based on clinical behavior & CT
findings. DPL or U/S(blunt) if unstable.

Intraoperative maneuvers
(options) for control &
access

Packing. Inflow occlusion (Pringle). Hepatic mobilization.

Sternotomy extension for exposure. Hepatic isolation (including
aortic clamp) or atrial-caval shunt.

Therapeutic options

Simple hepatorraphy. Packing w/planned return to OR.

Hepatotomy or wound tractotomy w/oversew of bleeding. R.
hepatic artery ligation for selected injuries. Resectional
debridement if necessary.

SPLENIC INJURIES (1)

62

Principal therapeutic goals Control of hemorrhage. Preservation of splenic function if possible.

Diagnosis/staging

Same as for hepatic injuries. Lower threshold for operative

intervention based on CT.

Intraoperative maneuvers
(options) for control &
access

Complete mobilization of spleen. Proximal hilar control. Necessary

for splenectomy or splenorrhaphy.

Therapeutic options

Splenectomy. Splenorrhaphy: suture, pledgets, wrapping, partial

splenectomy.

63

SPLENIC INJURIES (2)

nonoperative splenic management should generally
meet the following conditions:

(1) no evidence of hypovolemic shock, persistent or

recurrent splenic hemorrhage, massive
hemoperitoneum, or grade V injury;
(2) no anticipated need for transfusion requirements as
the result of splenic injury;
(3) no evidence of active extravasation or splenic
vascular injury seen on abdominal CT scan;
(4) no other indications for exploratory laparotomy;

(5) age less than 50 to 55 years; and

(6) no exacerbating factors such as coagulopathy or
portal hypertension.

64

PANCREATIC INJURIES

Principal therapeutic goals Control of associated hemorrhage. Control of exocrine secretions.

Diagnosis/staging

CT for diagnosis. (Injuries may be missed by DPL.) Threshold for

operative exploration should be low. DPL or U/S if unstable.

Intraoperative maneuvers
(options) for control &
access

Complete exposure of area of suspected injury. Thorough

assessment of major pancreatic duct (MPD) injury (inspection,
pancreatogram, ERCP).

Therapeutic options

Drainage only (contusions, minor lacerations). Distal resection

(MPD injuries) of body/tail.
Drainage w/sphincterotomy vs. resection (Whipple) for major
injuries to pancreatic head.

65

DUODENAL INJURIES

Principal therapeutic goals Control of associated hemorrhage. Control of GI secretions with

reestablishment of duodenal continuity. Maximizing suture line
durability.
Diagnosis/staging

Same as for pancreas. Isolated intramural hematomas may be

treated expectantly. Low threshold for operative exploration. DPL
or U/S if unstable. DPL for SW.

Intraoperative maneuvers
(options) for control &
access

Complete mobilization of duodenum: Kocher ligament of Trietz

takedown as needed.

Therapeutic options

Simple repair. Repair w/tube duodenostomy. Jordan modified

diversion (see text). Rouxen- Y jejunoduodenostomy for
augmentation. Resection for combined pancreatic head injuries
only.

66

COLORECTAL INJURIES

Principal therapeutic goals Reestablishment of GI continuity. Prevention of colon-related septic

complications.
Diagnosis/staging

CT poor for diagnosis of hollow-viscous injuries.

Intraoperative maneuvers
(options) for control &
access

Complete mobilization of involved region of colon. Flexible

sigmoidoscopy for rectal evaluation.

Therapeutic options

Primary repair for most penetrating colon & selected rectal injuries.
Diversion repair/
resection reserved for more severe combined injuries (colon) &
most rectal injuries.

67

Retroperitoneal Hematoma (1)

Zone 1 : central retroperitoneal hematomas

Zone 2 : perinephric hematomas
Zone 3 : pelvic hematomas

Retroperitoneal Hematoma (2)

Principal68
therapeutic goals Control of hemorrhage, avoidance of missed injuries.
Diagnosis/staging

CT preop. DPL insensitive and nonspecific. Hematomas graded

according to location: central, pelvic, perinephric.

Intraoperative maneuvers
(options) for control &
access

Retroperitoneal exploration indicated for all central hematomas.

Exploration indicated for all large, expanding, or pulsatile
perinephric hematomas. Pelvic fracture hematomas may be
packed if necessary, but should be explored only for suspected
major vascular injuries.

Therapeutic options

Repair of associated vascular, pancreatic, or renal injuries. Pelvic

fracture hemorrhage controlled by angiography embolization
pelvic external fixation.

C Clamp for
HAEMATOMA ZONA
III (PELVIS)

69

SUMMARY
Trauma Abdomen :
- Trauma tumpul
- Trauma tajam

intra &
retroperitoneal

Memilih modalitas diagnosis yang tepat

Kecurigaan Trauma Abdomen & Observasi yang ketat
Mengenal Trauma Abdomen yang memerlukan tindakan
bedah Rujukan
Intervensi bedah : Explorasi Laparatomi

70

REFERENCES
1.

Advanced Trauma Life Support,Seventh Edition. 2004:

American College of Surgeons

2.

Essential Practice of Surgery Basic Science and Clinical

Evidence. 2003: Springer

3.

Schwartz's Principles of Surgery, Ninth Edition. 2010: The

McGraw-Hill Companies, Inc

4.

Schein's Common Sense Emergency Abdominal Surgery, 2nd

Edition. 2005: Springer

5.

Trauma, 6th Edition. 2008: The McGraw-Hill Companies, Inc