Trauma Abdomen

UCR

Dr Daz Vargas

Trauma de Abdomen

CERRADO

PENETRANTE

OBJETIVOS
Enfoque diagnstico adecuado Ubicacin dentro de un todo
en el paciente politraumatizado Conocer el abordaje diagnstico Conocimiento bsico de abordaje teraputico

EXPLORACION FISICA
INSPECCION

EXPLORACION FISICA
PALPACION
TRAUMA CERRADO
(PALPACION PERCUCION)

TRAUMA PENETRANTE
(EXPLORACION DIGITAL)

EXPLORACION FISICA
AUSCULTACION

METODOS DIAGNOSTICOS
LAVADO PERITONEAL ULTRASONIDO TAC LAPAROSCOPIA ARTERIOGRAFIA RESONANCIA MAGNETICA

LAVADO PERITONEAL

Ventajas
Barato Anestesia

Desventajas
Sobre sensible Introduce aire y

local Muy sensible

lquido a cavidad Limita manejo conservador Poco especfico Invasivo

FAST
F OCUS A SSESMENT (A BDOMINAL) S ONOGRAPHY IN T RAUMA

Ultrasonido FAST
HIGADO SANGRE RION

LIQUIDO LIBRE

ULTRASONIDO FAST
Ventajas:

Rpido Barato Verstil Sensible Ms especfico que l.p. Puede ser repetido con frecuencia Puede ser realizado por no radilogos

Desventajas:

Operador No es

dependiente

especfico

sin palabras

TAC

TAC
VENTAJAS: Sensible Especfico Permite manejo
sin ciruga en pacientes estables Valora retroperitoneo

DESVENTAJAS: Consume tiempo Precio Dificultad de

controlar mientras se realiza el estudio Limitacin tcnica del equipo

LAPAROSCOPA
DESVENTAJAS

Requiere anestesia

VENTAJAS
Alta sensibilidad Permite teraputica en
algunos casos

general y equipo especializado Consume tiempo Eventual peligro de lesiones diafragmticas Dificil de valorar intestino

ALGUNAS NOVEDADES... POR EL MOMENTO

1. METODOS DIAGNOSTICOS 2. CONTROL DE DAO 3. S.COMPARTIMENTAL
4. 5. 6.

ABDOMINAL ABDOMEN ABIERTO BED SIDE LAPAROTOMY MANEJO NO QUIRURGICO

CONTROL DE DAO

CONTROL DE DAO

CONTROL DE DAO
ACIDOSIS

HIPOTENSION

HIPOTERMIA

TRIADA DE LA MUERTE

TRIADA DE LA MUERTE
HIPOTERMIA

COAGULOPATA

ARRITMIA - PARO CARDIACO

CONTROL DE DAO
HEMOSTASIA CONTROL DE CONTAMINACION

I- EN SALA DE OPERACIONES
CUAGULACION RESTITUCIN DE LQUIDOS

II- EN UCI O RECUPERACIN

TX. ACIDOSIS CALENTAMIENTO DEL PACIENTE

III-EN SALA DE OPERACIONES

100%

Sugrue M, D'Amours SK, Joshipura M Damage control surgery and the abdomen. Injury (England), Jul 2004, 35(7) p642-8

100%

Rotondo MF, Bard MR Damage control surgery for thoracic injuries. Injury (England), Jul 2004, 35(7) p649-54
Rosenfeld JV Damage control neurosurgery. Injury (England), Jul 2004, 35(7) p655-60 Kossmann T, Trease L, Freedman I, et al. Damage control surgery for spine trauma. Injury (England), Jul 2004, 35(7) p661-70
Henzan E [Damage control in vascular trauma] Nippon Geka Gakkai Zasshi (Japan), Jul 2002, 103(7) p521-3

100%

100%

Damage control surgery for thoracic injuries. Injury 2004 Jul;35(7):649-54 (ISSN: 0020-1383) Rotondo MF; Bard MR School of Medicine, East Carolina University, 600 Moye Blvd. Greenville, NC 27858-4354, USA. rotondo@pcmh.com.

Damage control of thoracic injuries begins frequently with an emergency department thoracotomy via an anterolateral incision. Bleeding and air leaks are quickly temporised. As opposed to abdominal damage control where most injuries can be temporised, most thoracic injuries require initial definitive repair. Thus, the goal of thoracic damage control is to perform the least definitive repair using the fastest and easiest techniques to shorten the operative time as much as possible. There are some injuries that can be temporised and require re-operation once physiologic normality has been achieved

-SINDROME COMPARTIMENTAL ABDOMINAL

-HIPERTENSION ABDOMINAL

Sndrome Compartmental Abdominal

TERCER ESPACIO ILEO PARALTICO EMPAQUE

DIFICULTAD EN EL CIERRE
O2 CO2

P INTRACRANEAL

AUMENTO P. TORACICA

AUMENTO DE PRESION INTRA ABDOMINAL

DISMINUCIN RETORNO VENOSO

ACIDOSIS

ISQUEMIA ESPLACNICA

DISMINUCIN GASTO CARDIACO

DISMINUYE PRESIN DE PERFUSIN INSUFICIENCIA RENAL

S. COMPARTIMENTAL ABDOMINAL

Clnicamente se caracteriza por: Distensin abdominal Incremento de la presin de inspiracin en la va area Aumento de la presin venosa central (PVC) Hipercarbia Hipoxia Oliguria

GRADOS DE HIPERTENSIN INTRAABDOMINAL.

Grado

Presin vesical en cm de agua

10-15 15-25 25-35 > 35

I II
III IV

CAUSAS S. COMPARTIMENTAL ABDOMINAL Espontnea Peritonitis y absceso intraabdominal leo, obstruccin intestinal Aneurisma artico roto Neumopritoneo a tensin Pancreatitis aguda Trombosis venosa mesentrica Postoperatoria Dilatacin gstrica aguda Hemorragia intraperitoneal Postraumtica Sangrado intraperitoneal/retroperitoneal Edema visceral posrresucitacin Iatrognica Procedimientos laparoscpicos Vestidos antichoque Empaquetamiento abdominal Reduccin masiva de hernia parietal o diafragmtica Cierre abdominal a tensin Crnica Ascitis Tumor abdominal de gran tamao Dilisis peritoneal ambulatoria Embarazo

S. COMPARTIMENTAL ABDOMINAL

DESCOMPRESION EXPANSIN DE VASOS ABDOMINO PELVICOS HIPOVOLEMIA RELATIVA

ARRESTO CARDIACO

RADICALES LIBRES
SIND. HIPOXIA REPERFUSION NETABOLISMO AEROBIO ION H ION K

Laparostomy

Bedside Laparotomy for Trauma: Are There Risks? Posted 06/01/2004 Jose J. Diaz, Jr.; Adele Mauer; Addison K. May; Richard Miller; Jeffery S. Guy; John A. Morris, Jr. Abstract and Introduction
Abstract Background: Critically ill trauma patients are often too unstable for safe transfer to the operating room. Damage control laparotomy patients frequently require early reoperation and have a reported mortality of 50-60%. As a result, many of these patients must undergo laparotomy in the intensive care unit. We hypothesized that patients undergoing bedside laparotomy (BSL) and managed with the abdomen left open would have an unacceptably high mortality or intraabdominal complications. Methods: We performed a retrospective chart review of our Trauma Registry. Of the 11,096 consecutive trauma admissions from March 1, 1996 to May 20, 2000, 75 patients underwent 95 BSL. Patients were stratified according to injury severity score (ISS), base deficit (BD), lactic acid (LA), total transfusion (TRBC) requirements, indication for BSL, mechanism of injury, infectious complications (intraabdominal abscess (IAA), fistula), and length of hospital stay. Results: Seventy-five patients underwent 95 BSL. Mean ISS was 50.6 18.9, mean BD was -11.9 ( 5), and the mean LA was 5 5 for the study group. The TRBC for the group was 43.7 42.6 units. Indications for the 95 BSL were (1) abdominal compartment syndrome ( n = 47, 49.5%); (2) suspected intraabdominal infection (n = 18, 19.0%); (3) washout/pack removal (n = 14, 14.7%); (4) washout with fascial closure (n = 12, 12.6%); and (5) other (n = 4, 4.2%). Twentynine of 75 patients (39.2%; ISS 52.3 18.8) died within 72 h of operation. Of the 46 remaining patients, an additional eight died 72 h or more after operation, for a late mortality rate of 17.4% and a total mortality rate of 49%. None of these deaths were attributable to either the operation or to postoperative IAA or fistula formation; all late deaths were secondary to multiple organ failure. Intraabdominal abscesses developed in three of 46 patients (6.5%), each of whom had a TRBC of > 100 units (mean, 160 units). Five of 46 patients (10.9%) developed enterocutaneous fistulae. None of these eight patients died. Thirtyeight of 75 patients (50.7%) survived to discharge, with a mean ISS of 40 ( 11.9). Conclusions: Despite the high acuity of the population undergoing BSL, 50.7% of patients survived. Moreover, during BSL, IAA and fistula formation occurred at low rates. Introduction In the early 1990s, reports of damage control laparotomy for abdominal trauma began to appear in the medical literature. [1,2] Damage control laparotomy patients present in extremis, frequently require early reoperation, and have a reported 50-60% mortality rate.[3,4] Concurrently, advances in critical care management of the severely injured trauma patient are allowing many patients who would previously have died to survive the initial injury. As such, trauma centers are caring for an increasing number of critically ill patients who are often too unstable for safe transfer to the operating room. This often manifests as ventilatory requirements that are too high for either bagmask ventilation or a transport ventilator, or a sudden change in the patient's pathophysiology such that the brief time needed for transportation and preparation of the operating room would be nonsurvivable. As a result, many of these patients require bedside laparotomy (BSL) in the intensive care unit (ICU) accepting the known limitations of inadequate lighting, lack of a sterile environment, absence of trained operating room personnel, and limited surgical instruments. An adjunct to damage control in the management of the trauma patient, a protocol for BSL should be prepared before an emergent need for bedside surgery. [5] With the recognition of the abdominal compartment syndrome, bedside surgical decompression has become more common as a lifesaving procedure.[6] As a result, the occurrence of trauma patients managed with an open abdomen has become commonplace. We hypothesized that patients undergoing BSL and managed with an open abdomen would have an unacceptably high mortality rate or incidence of intraabdominal complications.

MANEJO NO QUIRRGICO

Manejo Conservador
Laparotomas Innecesarias
Renz 1995 27.1% negativas laparotomas incluyendo
penetrantes y no penetrantes

Wigelt 1988 1.2% lesiones Iatrognicas 16 publicaciones colectivamente 20.6% por Penetrante 20% por no penetrantes

Trauma Abdominal Cerrado

Lesiones que pueden ser seguidas
conservadoramente
Hgado Bazo Fracturas plvicas Hematomas retroperitoneales Excpto: Hematomas pancreaticoduodenales

Lesiones Hepticas Complejas

495 lesiones hepticas 94% de xito con tratamiento conservador

1. Pachter HL, Hofstetter SR. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995;169:442454.

Lesiones Hepticas Complejas

Promedio de transfusiones 1.9

unidades 6.2% de complicaciones
2.8% relacionadas con la hemorrgia

13 das de promedio de
internacin

1. Pachter HL, Hofstetter SR. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995;169:442454.

Lesiones Hepticas Complejas

404 casos de lesiones cerradas

hepatica estudio multiinstitucional 98.5% de xito evitando una intervencin quirrgica 5% de complicaciones

Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma 1996;40:3138

Lesiones Hepticas Complejas

Complicaciones
(3.5%) continuaron sangrando, solo 3 pacientes requirieron ser intervenidos para controlar la hemorragia (0.7%) 1.5% formacin de bilomas.

Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma 1996;40:3138

Manejo Conservador
La otra cara de la moneda
Lesiones no identificadas 3.4% La morbilidad es aceptable

Para tener xito en manejo no operatorio

se necesita
Tecnologa Encimologa Olfatologa
Dr ludi

FABIAN

Lesiones de pelvis

Clasificasion
APC anterior-posterior compresion
Type I: Isolated pubic diastasis and/or pubic ramus disruption < 2.5 cm

Type II: Anterior ramus fractures and/or diastasis >2.5 cm with widened SI joint (s). Totationally unstable
Type III: Disruption of symphysis or significant Separation of anterior vertical ramus fractures. Disruption of anterior/posterior ligamets of SI Joint.Totationally and vertically unstable

LC (Lateral Compression)
Type I: Horizontal fractures of pubic rami. Impaction injury/fracture of sacrum Type II: Horizontal fractures of pubic tam with ligamentous or Bony disruption of SI joint Type III: Horizontal fractures of pubic rami with contralateral Ramus and SI joint disruption (APC type injury)

VS (vertical shear)
Complete bony and ligamentous disruption of hemipelvis with Vertical displacement

Fracturas Plvicas y Embolizacin

Pacientes estables: Mortalidad 3% - 8%

Pacientes inestables: Mortalidad 42% - 50%

Muertes durantes las primeras 24 horas

EAST Guidelines
Qu pacientes deberan tener una agiografa y
posible embolizacin???
Pacientes con fracturas plvicas con signos de un sangrado activo despus que se ha descartado otra fuente de sangrado Pacientes con fracturas plvicas mayores que durante la laparotoma exploradora no se pudo controlar el sangrado Pacientes con evidencia de extravasacin arterial de contraste en la pelvis durante una TAC

Entendiendo la fisiologa
La pelvis es una gran cavidad Control del sangrado
Venoso por taponamiento va a necesitar grandes volumenes de sangrado Con grandes consumos de
Sangre entera Factores de Coagulacion

Arterial probablemente no va a parar De los huesos fracturados

Embolizacin
Problemas
Alto porcentaje de negativos 20% + Alta mortalidad debido a lesiones concomitantes Todava no bien estudiado los efectos a largo plaso de las embolizaciones bilaterales Impotencia????

BIBLIOGRAFIA

Meyer AA: Abdominal Compartment Syndrome: A new problem or a newly

recognised old problem? 85TH Clinical congress of the American College of Surgeons. Oct 10-15, 1999. San Francisco. California. Summary conference index. Medscape 1999 Ivatury RR, Porter JM, Simon RJ, et al: Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophilaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome. J Trauma 1998 Jun; 44 (6): 1016-21 Bloomfield, G., Saggi, B., Blocher, C, & Sugerman, H. (1999). Physiologic effects of externally applied continuous negative abdominal pressure for intra-abdominal hypertension. Journal of Trauma: Injury, Infection and Critical Care. Jun; 46(6): 1014-6. Diebel, L., Dulchavsky & S., Brown, W. (1997). Splanchnic ischemia and bacterial translocation in the abdominal compartment syndrome

Offner, P. & Burch, J. (1998). Abdominal compartment syndrome, part

1: presentation and workup: cardiopulmonary and renal findings are among the most prominent signs. Journal of Critical Illness. Oct; 13(10): 634-8. Offner, P. & Burch, J. (1998). Abdominal compartment syndrome, part 2: management guidelines: which patients will require abdominal decompression? Journal of Critical Illness. Oct 13(10): 639-42.

Quiero vivir la vida aventurera de los errantes pjaros marinos...

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GRACIAS