Penetrating abdominal injuries-د.نضال يونس

Penetrating abdominal injuries

للدكتور نضال يونس

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http://www.4shared.com/file/68730972/50414399/Penetrating_abdominal_injuries.html

بالتوفيق

Penetrating abdominal injuries
Done by: Rana jallad
22.10.2008
Prof. Nidal Younes

A Case Scenario...
A 28 years old male patient, with no known medical illnesses, presented to the ER with a stab wound in the abdomen near the midline below the umbilicus, one hour after sustaining the injury. He arrived conscious but started to feel drowsy and presented with evisceration of small bowel.
His blood pressure was 80/50
Hemoglobin was 11
White blood count was 30,000

Note:
Evisceration means something coming out from the abdomen to the outside, and it can be in the form of omentum, small bowel or colon depending on the trauma and the wound

 There are so many causes of penetrating abdominal injuries, and the most common in our part of the world are stab wounds, other causes include Gun shoot wounds and Shoot gun wounds.

 The difference between Gun shot wounds and Shot gun wounds:
Gunshot machines: their kinetic energy is very high with massive destruction, they can reach to very distant points and still can cause damage (direct daage as well as cavitery changes) due to the high kinetic energy.
Shotgun machines: if the person is not close enough, within 6-10m, then the effect is not that much destructive, due to their low kinetic energy, so it may only penetrate the skin then stops.

Effect of stab wounds compared to gunshot wounds is smaller.


The question now is how we can approach such patients (like the one in our scenario)?
Always start with the ABCD approach, whenever you have a chest injury or abdominal injury or any kind of injury, you approach them all in the same way.

A: Airways ; being adequate and patent.
Check that nothing is obstructing the upper airways and that the tongue is not getting backwards.
B: Breathing ; being in a normal way!
C: Circulation.
Resuscitation is part of C, so you never start with resuscitation before checking A & B first.

‘Before going to the specific problem, you should make sure that other things are being taken care of’.

The ABCD approach is part of what is called The Initial Primary Survey.

The Initial Primary Survey of all trauma victims includes ABCD and treatment of the life threatening conditions at the same time simultaneously.

The second step is The Secondary Survey; which includes examining the patient from head to toe.

Back to our patient: there was nothing in his airways or breathing, he came walking to the ER and was having evisceration of the small bowel , obviously this patient has a problem with C , so what is the evidence of this problem?
The evidence is that his BP= 80/50, meaning that the patient is in shock [where BP less than 80/60 is considered shock]. So, you should immediately do cannulation for him and start injecting I.V. fluids .

Why to start with fluids (i.e. crystalloids)?
1. We usually don’t have blood to start with.
2. The initial management of trauma patients is resuscitation with crystalloids
Then you take blood samples for cross matching and transfusion.

So our patient was given ringer lactate (that is usually used in the ER), he was given 20cc/kg, and his blood pressure started to improve, but the patient is still having evisceration.



We said at the beginning that the patient’s Hb was 11, does this reflect that the patient is in shock?
No, it doesn’t, where measuring the Hb or Hct 30 minutes or an hour after the injury does not reflect the real situation, and having them normal immediately after the trauma doesn’t rule out significant bleeding, for they need time before getting down.

We said before that:
 50% of trauma patients will die at the scene of the accident, and those deaths can’t be saved, and there is nothing one can do to them except for telling people and advising them not to drive fast or under the influence of alcohol or not to use weapons…etc.
 30% of the trauma patients die within 1-3 hours after the trauma, and that’s called the golden 3 hour period, so you have to act quickly, there is no time to waste.

Now… our patient is still having evisceration, what to do next?
The possibility of perforation should be raised out in such patients.

Whenever a person has a stab wound injury, you should keep in mind the possibility of liver injury, colon injury, spleen or small bowel injury.

There is a big difference between the mechanism of penetrating and blunt abdominal traumas:
 When talking about blunt traumas, then mostly we are concerned with spleen and liver injuries, but unlikely to have small bowel injury by blunt trauma.
 When talking about penetrating injuries and stab wounds, then there is a high incidence of having small bowel injury.

When talking about penetrating abdominal injuries, you should keep in mind 2 things:
1. The bleeding problem caused by injury to the liver and spleen.
2. Peritonitis problem which results from perforation of viscous.

So in our patient the possibility of perforation is there, specially when saying that the bowel was outside, indicating that the trauma was of significant magnitude that it penetrated the abdominal wall and fascia to the inside.




What to do next?
We have 2 options:
1. Exploration of the wound
2. Exploration of the abdomen
Which are different things.

 Exploration of the wound is performed when the patient is hemodynamically stable
 Immediate exploration (exploration of the abdomen) is performed when the patient is hemodynamically unstable.

Note:
Hemodynamically stable patient means that:
 he is already having normal vital signs,
OR
 that they were not normal but he responded to our trials in correcting them by fluids and other managements.

But if there was no response and the vital signs are still deteriorating whatever you try then this is hemodynamically unstable patient.

Peritonitis that results from perforation of the hollow viscous does not present in the first few hours after injury, it takes some time to develop.
If the patient within the first few hours was hemodynamically stable then this gives you some time to work up the patient and do further investigations to evaluate the situation, but that does not exclude the possibility of perforation.


 Wound exploration:
What is the value of wound exploration in penetrating abdominal injuries?
To evaluate the depth of the wound; whether it is superficial (limited to the abdominal wall) or deep (reached the abdominal cavity).
The ideal place for doing wound exploration is in theater, whether a special theater in the ER or one of the theaters in OR.




كيف بنعملها؟
منيجي على الووند ومنكبرو من أطرافه (اتجاه الأسهم في الرسمة) و منشوف لحد وين واصل.







After doing the wound exploration we have two possibilities:
A. the rectus sheath and fascia are intact; this means that the trauma did not penetrate down to the peritoneoum.
In such cases….do management of superficial traumatic wounds.

B. The posterior rectus sheath is open; this means that the trauma reached the peritoneal cavity, and here again we have two possibilities:
1. it has reached the cavity but did not create any problem.
2. it has reached the cavity and hit one of the organs inside it (Small intestine ,colon ,liver or spleen).
How can we tell if the organs are affected by the stab or not?
Of the investigations that can be done are:
1. Peritoneal lavage:
One of the indications to do peritoneal lavage is that you have done wound exploration (for a stable patient) and found that the stab has reached the abdominal cavity but you want to know if there is any organ damage or not (again!!).
 This is done by introducing a catheter into the peritoneal cavity and do aspiration; if the aspiration contains more than 10 cc of unclotted blood then that is an indication for immediate (abdominal) exploration.
 Most of the time nothing gets out of the catheter and you wonder that maybe the patient is having minute bleeding or small bowel extravasations that can not be aspirated by the catheter, in this case, wash the abdomen with one liter of fluids and try to collect it to the outside, then do analysis to this peritoneal lavage according to specific parameters including the WBC, RBC, if there are food particles…etc. what matters in penetrating abdominal injuries are the WBC and the RBC where:
WBC  500
RBC > 100,000 then this is significant bleeding that requires immediate exploration.
The popularity of peritoneal lavage has declined with the discovery of CT scan. Also the pertitoneal lavage is not 100% accurate ,it has a high incidence of false positive result (e.g.only having small laceration of the liver or spleen but peritonel lavage is positive; once you open you discover that these had sealed off and that the patient does not require surgery).
So the peritoneal lavage is so sensitive but is not specific.

2. Fast abdominal sonography for trauma patients:
This is available in USA and south east Asia but not in Jordan. it is ultrasound present in the ER that you can run quickly on the abdomen of the patient and look for fluids in the abdominal cavity.
 Any fluid that accumulates in any cavity following trauma is blood until proven otherwise.


 Abdominal exploration:
Why do we do abdominal exploration?
Looking for complications; the most important complication is the possibility of perforation.

Now… our patient has two indications for surgery (immediate abdominal exploration):
1. evisceration of small bowel.
2. hemodynamically unstable (he was in shock).
This patient was shifted immediately to the theater.

Our patient had abdominal exploration and turned out to have multiple lacerations in the mesentery of bowel and had perforation in at least two to four spots of the small bowel
they were very precise perforations with no tissue destruction.

For the lacerations; the vascularity of the bowel was checked and it was good so they were closed primarily and no resections and anastomoses were done, and every other organs were okay.
Perforations also were closed primarily.

If the patient had significant lacerations that lead to cut off the blood supply, an area of small bowel would have been avascularized and we should have done resection of that area and small bowel anastomosis.


Traumatic wounds in terms of infection are classified into:
1. Contaminated
2. Infected.
There are no clean, clean contaminated and dirty traumatic wounds.

The most important thing to differentiate between contaminated and infected wounds is Time.
< 6 hours…..contaminated.
> 6 hours…..infected.

Notes:
1. Surgical wounds are classified into: clean, clean contaminated, contaminated and dirty.
2. Small bowel contents do not cause dirty wounds.

In our scenario the patient has contaminated wound (he came after an hour of sustaining the injury).
The wound of our patient was treated according to the lines of treatment of contaminated wounds which includes:
1. Irrigation of the skin wound.
2. Removal of all necrotic and damaged tissues.
The same was done for the abdominal wounds, then he was given antibiotics.

Notes:
1. In gunshot wounds we tend to explore the patient!!
2. The WBC of our patient was 30,000,due to:
1. stress response
2. perforation.
3. The difference between laceration and perforation:
 Perforation: is a wound extending from the lumen of a hollow viscous to the outside and is associated with leak of the GI contents to the outside.
 Laceration: is used for skin, subcutaneous tissue and superficial wounds.
We don’t say perforation of skin but laceration.
We don’t say perforation of muscles but laceration, because nothing is coming out of the muscle.
We say perforation of the stomach, small bowel, esophagus or bronchus.
The End