ABDOMINAL TRAUMA

Splenic trauma Principles of Management

ABDOMINAL TRAUMA
Mechanics
Blunt trauma
RTA, Falls, fist injuries, etc

Penetrating injuries
Stab wounds: knifes, arrows, spears etc. Fire arm injuries (missiles)

PENETRATING INJURIES
SI >liver>spleen are frequently involved
Increasing incidence in civilian life Low velocity high velocity

Missile wounds
Damage by direct trauma, shock wave and temporary cavitations Viscera not on the missile tract may be damaged Almost always need exploration Consider missile tract in evaluation Lower chest wounds may involve abdomen

PENETRATING INJURIES: Diagnosis

Is the peritoneum intact or violated?
Peritoneal irritation signs

Local wound exploration

Plain abdominal X-rays When in doubt, explore

BLUNT INJURIES
Abdominal cavity not breached Multiple organs may be involved Injury Types: crushing, contusions, haematoma, soft tissue fractures Organs involved varies between localities Spleen>Kidneys>intestine>liver Most of those that die have liver and splenic injuries

BLUNT INJURIES: Diagnosis

High index of suspicion
HX of significant abdominal trauma

Features of shock/unstable CVS

Peritoneal symptoms and signs Specific organ features

BLUNT ABDOMINAL INJURIES: Diagnosis

Falling PCV
Rising WBC Increased amylase Paracentesis abdomini ( 4 quadrant tap)
Indications limitations

ABDOMINAL INJURIES: Diagnosis

Diagnostic peritoneal lavage (DPL)
Indications Practical steps Interpretation Precautions Limitations

BLUNT ABDOMINAL INJURIES: Diagnosis

CXR
Hollow viscus # ribs

Plain abdominal X-ray Abdominal USS CT abdomen IVU Selective angiography, Isotope scan

ABDOMINAL INJURIES: Principles of management

Primary survey
ABC of resuscitation

Secondary Survey
Detailed history
Circumstances of injury Suggestive symptoms of particular organ injury

ABDOMINAL INJURIES: Principles of management

Physical examination
Features of CVS instability/shock External signs of injury Peritoneal signs Missile trajectory

ABDOMINAL INJURIES: Resuscitation

Stabilize the CVS Monitor urine output Decompress stomach Stop external bleeding Relieve pain Antibiotics Basic Investigations
PCV, Blood grouping and CXM

ABDOMINAL INJURIES: Diagnosis

Is significant intrabd. Injury established?
What organs are involved? Does the injury merit operative treatment?

ABDOMINAL Trauma Treatment

Mid line exploratory laparotomy Organ specific procedures
Stomach Liver, Gall bladder SI, LI Kidneys Bladder Pancreas Duodenum

SPLENIC TRAUMA
EPIDEMIOLOGY
Most commonly injured in blunt trauma

Second to SI & liver in penetrating

Enlarged spleen increases chances

SPLENIC TRAUMA
PRESENTATION
Ultra urgent

Early presentation
Delayed presentation

SPLENIC TRAUMA: Diagnosis

HX of suggestive injury
Suggestive physical signs

Specific signs: Kehrs sign, Balances sign

CXR features

USS
CT scan

SPLENIC TRAUMA: Treatment

Non Operative treatment
Reasons: Functions of the spleen

Indication
Contra indications Guiding principles

SPLENIC TRAUMA: Operative Treatment

Splenic conservation Surgery
Reasons Methods Contraindications

Splenectomy

Splenorrhaphy: Indications
Hemodynamically stable

No serious head injury

No other potentially life threatening injury

Bleeding grade I-III injury

Splenorrhaphy: Partial Splenectomy Stapled

GIA stapled partial splenectomy

Splenorrhaphy: Partial Splenectomy

Partial, anatomic resection after vascular ligation Pledgeted closure of raw surface

Indications for Splenectomy : Intra-op Diagnosis

Moderate or severe traumatic brain injury Actively bleeding or devascularized spleen Coexisting injury at high risk for hemorrhage Coagulopathy

SPLENECTOMY: Complications
Haemorrhage Gastric injuries Pancreatic injuries/pancreatitis Subphrenic collections Post op thrombosis embolism Fulminant malaria OPSI

Overwhelming Postsplenectomy Sepsis (OPSS)

Encapsulated organisms: Pneumococcus Meningococcus H. Flu <1% incidence More important in pediatric age range Immunization timing controversial

Streptococcus pneumoniae

OPSS
Most common etiologic agent is Streptococcus pneumonia severe hypoglycemia, electrolyte imbalance, shock, DIC are frequent clinical findings. Though the incidence is < 1%, the fatality rate is up to 50 %. Vaccines do not provide protection against all forms of bacterial pneumonia. Immunization for all three organisms will cover 90% of all encapsulated organisms