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Penetrating Abdominal Trauma.doc (112 KB) Pobierz Background Penetrating abdominal trauma typically involves the violation of the abdominal cavity by a gunshot wound (GSW) or stab wound. The management of penetrating abdominal trauma has evolved greatly over the last century. Before World War I, penetrating trauma was managed expectantly and was nearly uniformly fatal. Laparotomy became the treatment of choice during World War I, but mortality remained high. By World War II, early laparotomy resulted in a survival rate close to 50%. The 1950s afforded availability of antimicrobials, better understanding of fluid replacement, and faster transport from the scene, which further increased survival rates. By the late 1950s, mandatory laparotomy was the rule for the management of patients with abdominal penetrating trauma. In 1960, Shaftan suggested selective management of patients with abdominal stab wounds after observing an increased rate of laparotomies without identifiable injuries. More recently, expectant management has also been used in the treatment of specific GSWs to the abdomen… Anatomy In evaluating patients with penetrating abdominal trauma, the abdomen is classically divided as follows: Anterior abdomen - Anterior costal margins to inguinal creases, between the anterior axillary lines Intrathoracic abdomen or thoracoabdominal area - Fourth intercostal space anteriorly (nipple) and seventh intercostal space posteriorly (scapular tip) to inferior costal margins Flank - Scapular tip to iliac crest, between anterior and posterior axillary lines Back - Scapular tip to iliac crest, between posterior axillary lines. This anatomic classification is important in guiding the clinician’s suspicion for specific organ injury. Intraperitoneal abdominal organs include the solid organs (ie, spleen, liver) and the hollow viscus organs (ie, stomach, ileum, jejunum, transverse colon). Retroperitoneal organs include the duodenum, pancreas, kidneys, ureters, urinary bladder, ascending and descending colon, major abdominal vessels, and rectum. Pathophysiology A GSW is caused by a missile propelled by combustion of powder. These wounds involve high-energy transfer and, consequently, can involve an unpredictable pattern of injuries. Secondary missiles, such as bullet and bone fragments, can inflict additional damage. Military and hunting firearms have higher missile velocity than handguns, resulting in even higher energy transfer. In penetrating abdominal trauma due to gunshot wounds, the most commonly injured organs are as follows: Small bowel (50%) Colon (40%) Liver (30%) Abdominal vascular structures (25%) The severity of shotgun wounds depends on the distance of the victim from the weapon. The mass of a shot pellet is minimal, and thus its velocity decreases rapidly after the shell leaves the barrel of the gun. When the distance is less than 3 yd, the injury is considered high velocity; if the distance exceeds 7 yd, most of the buckshot penetrates only the subcutaneous tissue. Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked, resulting in devastating complications. In penetrating abdominal trauma due to stab wounds, the most commonly injured organs are as follows: Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%) The mechanism that underlies the penetrating trauma (eg, gunshot wound, stab wound, impalement) relates to the mode of injury (eg, accidental or intentional injury, homicide, suicide). Homicide or intentional injury is the predominant mode of abdominal injury in this patient population. Accidental injury is most common in pediatric home firearm injuries but is uncommon by comparison to the overall levels of homicide and intentional injury. Suicide via penetrating abdominal trauma is uncommon. Etiology Gunshot wounds, considered high-velocity projectiles, are the most common cause (64%) of penetrating abdominal trauma, followed by stab wounds (31%) and shotgun wounds (5%). Penetrating abdominal trauma may result from urban violence. Domestic violence crosses all socioeconomic barriers and is an important consideration in the evaluation of injuries sustained at home and those reportedly involving the patient's family or significant other. From a global perspective, penetrating abdominal trauma in most settings results principally from military actions and wars. Penetrating abdominal trauma may be iatrogenically introduced. Documented complications of diagnostic peritoneal lavage include injuries to the underlying bowel, bladder, or major vessels such as the aorta or vena cava. Fortunately, the incidence of such complications is relatively small. Epidemiology United States statistics In the United States, suicide and homicide consistently rank in the top 15 causes of death. According to data published by the National Vital Statistics Reports, 11,406 homicide deaths occurred from firearm injuries in 2009 and 18,689 deaths from self-inflicted GSWs. Forty percent of homicides and 14% of suicides by firearm involved injuries to the torso. Tracking trauma is the purview of the National Center for Injury Prevention and Control (NCICP). Data collected by this organization suggest that traumatic injury is the third overall leading cause of death and the number one cause of death in persons aged 1-44 years. Penetrating abdominal trauma affects approximately 35% of those patients admitted to urban trauma centers and 1-12% of those admitted to suburban or rural centers. International statistics According to age-adjusted rates from 1990 to 1995, firearm mortality rates across the world vary widely, from 0.05 in Japan to 14.24 in the United States. Firearm-associated homicide mortality was highest in Mexico at 10.35; firearm associated suicide was highest in the United States at 6.3. The frequency of penetrating abdominal injury across the globe relates to the industrialization of developing nations, weapons available, and, significantly, to the presence of military conflicts. Therefore, frequency varies. Racial differences in incidence Age-adjusted firearm death rates are 2-7 times higher for non-Hispanic black males than for males of other ethnicities. For non-Hispanic whites, most firearms deaths are due to suicide. Sex- and age-related differences in incidence Males constitute the great majority of patients with penetrating trauma injuries across the United States and the world. In some areas of the United States, approximately 90% of patients with penetrating trauma are male. Injuries are the leading cause of death in patients aged 1-44 years. Prognosis The death rate from penetrating abdominal trauma spans the entire spectrum (0-100%), depending on the extent of injury. Patients with violation of anterior abdominal wall fascia without peritoneal injury have a 0% mortality rate and minimal morbidity rate, while those with multiorgan injury complexes presenting with hypotension, base deficit less than -15 mEq/L HCO , core temperature less than 35° C, and development of coagulopathy have a dramatically increased mortality rate mandating "damage control" resuscitation. 3 An average mortality rate for all patients with penetrating abdominal trauma is approximately 5% in most level 1 trauma centers, but this population is necessarily biased, given the higher acuity seen at such centers, thus skewing the data. Survival from penetrating abdominal trauma has not measurably changed in the past decade, largely because of death within 24 hours resulting from irreversible hemorrhagic shock and exsanguination. More than 80% of deaths occur within 24 hours of admission, 66.7% at the initial operation associated with abdominal vascular injury. In contrast, survival from penetrating abdominal injury without vascular injury remains high. General factors that predict increased mortality from penetrating abdominal trauma include the following: Female sex Long interval between injury and operation Presence of shock on admission Coexisting cranial injury The death rate is markedly influenced by prehospital hypotension, massive hemorrhage, arrest in the field or on presentation, acidosis with an initial pH less than 7, lactate level greater than 20 mmol/L, or base deficit more negative than -15 mEq HCO . 3 In a series by Nicholas and colleagues of 250 patients with penetrating abdominal trauma and positive laparotomies, the overall survival was 86.8%. Mortality was found to be associated with the number of organs injured, vascular injury, and the need for damage-control surgery, emergency department thoracotomy, or operating room thoracotomy. While damage-control surgery has been used with some success in the management of patients with extensive abdominal trauma, it is associated with significant morbidity, including sepsis, intra-abdominal abscess, and gastrointestinal fistula, according to Nicholas et al. Patients who present to the ED in the early postoperative period with abdominal pain or signs of infection should be strongly considered for CT scan and surgical consultation. Injury patterns differ depending on the weapon. Low-velocity stab wounds are generally less destructive and have a lower degree of morbidity and mortality than gunshot wounds and shotgun blasts. Gunshot wounds and other projectiles have a higher degree of energy and produce fragmentation and cavitation, resulting in greater morbidity. History The history provides clues to the most likely injury patterns and potential management priorities. Emergency medical services (EMS) personnel are often essential in providing a history, especially in a critically ill patient or one with altered mental status. A common acronym describing important information to gather when taking the history is AMPLE, as follows: Allergies Medications Prior illnesses and operations Last meal Events and environment surrounding injury The anatomic location of injury and type of weapon (ie, gun, knife) direct the diagnostic process. Information such as the number of gunshots heard or the number of times the patient was stabbed, and the patient’s position at the time of injury help describe the trajectory and path of the injuring object. Close-range injuries transfer more kinetic energy than those sustained at a distance, although range is often difficult to ascertain when assessing gunshot wounds. Blood loss at the scene should be quantified as accurately as possible from EMS personnel. However, research has shown that this assessment is very difficult and rarely reliable. The character of the bleeding (eg, arterial pumping, venous flow) may assist in determining whether major vascular injury has occurred. The initial level of consciousness or, for moribund patients, the presence of any signs of life at the scene (ie, pupillary response, respiratory efforts, heart rate or tones) is vital to determine the prognosis and to guide resuscitative efforts. Particularly important is the patient's response to therapy en route to the ED. Evidence of hypotension in the field should raise suspicion for intra-abdominal injury. Physical Examination Assessment of the patient begins at the scene of the incident by EMS personnel. Upon arrival at the emergency department (ED), communication of the incident history and the patient’s vital signs to the emergency or trauma team is of paramount importance. The initial physical examination begins with visual assessment of the patient during transport into the ED, with particular focus on the ABCs. Rapid determinations regarding respiratory effort, perfusion, external hemorrhage, and consciousness level are usually easily made. Confounding injuries or medical problems, such as tension pneumothorax or acute myocardial infarction, need be excluded. Initial vital signs assist in determining injury severity and need for operative intervention. Hypotension, narrow pulse pressure, tachycardia, high or low respiratory rate, or signs of inadequate end organ perfusion in the setting of penetrating abdominal trauma provide evidence of significant intra-abdominal injury, especially vascular trauma, and warrant immediate surgical exploration. Examination of the abdomen in a patient who is awake may indicate peritoneal signs, such as pain and guarding and rebound tenderness. Hemodynamically stable patients with penetrating abdominal trauma and peritonitis can be assumed to have a hollow visceral perforation and may have significant intraabdominal hemorrhage. Thus, peritonitis on physical examination is a trigger for emergent intervention regardless of vital signs. Peritoneal signs develop when the peritoneal envelope and the posterior aspect of the anterior abdominal wall are both inflamed. The peritoneal or retroperitoneal blood and organ contents inflame deeper nerve endings (visceral afferent pain fibers) and result in poorly defined pain. Irritation of the parietal peritoneum leads to somatic pain, which tends to be more localized; however, the diffuse nature of intra-abdominal spillage often leads to diffuse findings. Referred pain may provide a clue to organ damage. For example, left shoulder pain may result from a damaged spleen with subphrenic blood. Abdominal distention in an unresponsive patient may indicate active internal bleeding. In hypotensive patients, this may be an indication for immediate exploration. Focused Assessment With Sonography for Trauma (FAST) examination can be useful in this situation to detect massive hemoperitoneum. Rectal examination is performed on all patients with penetrating abdominal trauma, because blood per rectum and, in males, high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively. Notation of blood at the urethral meatus is also a sign of genitourinary tract injury. Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds. Multiple wounds may represent either entrance or exit wounds and must not be labeled as such, since multiple missiles or foreign objects may be retained within the body. Wounds located on the anterior abdomen can be explored locally to determine whether they penetrate the peritoneum. On the flank area and back area, exploration is more difficult and less reliable. Therefore, flank and back wounds are not explored and are considered penetrating unless obviously superficial. When immediate operative intervention is not requisite, further evaluation ensues with laboratory testing and diagnostic and imaging studies. Patients without recordable cardiac activity upon presentation should not be further resuscitated. Primary survey The primary survey is defined by the mnemonic ABCDE: Airway, Breathing, Circulation, Disability, and Exposure/Environment. Although described sequentially, much of this evaluation may be performed simultaneously and problems identified are managed immediately. The airway is assessed immediately for patency, protective reflexes, foreign body, secretions, and injury. Breathing is assessed by determining the patient's respiratory rate and by subjectively quantifying the depth and effort of inspiration. The circulation assessment begins with an evaluation of the patient's mental status, skin color, and skin temperature. Patients in significant hemorrhagic shock will progress from anxiety to agitation and finally coma if their blood loss continues unabated. The traditional vital signs of heart rate, blood pressure, and respiratory rate are not sensitive or specific for hemorrhagic shock. Disability is assessed early to document neurologic deficits before giving sedation or paralytics. The Glasgow Coma Score and the gross motor and sensory status of all 4 extremities should be determined and recorded. The physician should recognize the need for cerebroprotection measures in cases of brain injury. Hypotension and hypoxemia exacerbate secondary brain injury and increase mortality by 50% in patients with traumatic brain injury. Exposure is particularly important in the patient with a traumatic mechanism of injury, in whom it may disclose additional, potentially life-threatening injuries. Complete exposure and head-to-toe visualization is mandatory in a patient with penetrating abdominal trauma. This includes the buttocks, posterior legs, scalp, posterior part of the neck, and perineum. There is little to be gained by practicing spinal immobilization unless spinal injury is obvious. Once the primary survey is complete, a complete head-to-toe physical examination is performed as an integral part of the secondary survey, including digital rectal and genital examinations. This detailed examination may need to be delayed until after operative therapy has corrected obvious life-threatening injury. Secondary survey and injury assessment External inspection for injuries with respect to anatomic landmarks aids identification of possible intracavitary injury. Common physical examination recommendations include evaluation for tympany (a bell-like or percussive note upon gently tapping on the abdomen), dullness to percussion, and bowel sounds. Abdominal distention, not clearly due to "bagging" or swallowed air, may be an indicator of an intra-abdominal catastrophe. A vascular injury is often found in combination with hollow or solid viscus penetration or devitalization. The physical examination is a more reliable indicator for surgical intervention with penetrating abdominal trauma than with blunt trauma. At many trauma centers, repeated abdominal examinations are the preferred approach for managing hemodynamically stable patients with penetrating abdominal stab wounds. When selective nonoperative management is used, the indications for operative intervention include the development of hemodynamic instability or the development of increasing pain, peritoneal findings (eg, point tenderness, involuntary guarding, rebound tenderness), or diffuse and poorly localized pain that fails to resolve. Evisceration has historically been a clear indication for operative management. However, some centers replace eviscerated omentum and serially observe or image these patients. Impaling objects may tamponade otherwise uncontrolled hemorrhage if the object resides within or crosses a major vessel or solid organ such as the portal vein or liver. Therefore, penetrating objects should not be removed except where definitive treatment can be provided. For patients with abdominal stab wounds, a policy of observation and serial examination with discharge in 10-12 hours of patients with negative findings has been proposed. While studies have shown promising results, this approach has not been fully validated in multiple centers. Approach Considerations The approach to patients with penetrating abdominal trauma depends on whether the injury is a gunshot wound (GSW) or a stab wound and the patient’s hemodynamic status. GSWs are associated with a high incidence of intra-abdominal injuries and nearly always mandate laparotomy. Stab wounds are associated with a significantly lower incidence of intra-abdominal injuries; therefore, expectant management is indicated in hemodynamically stable patients. Many protocols have been developed for determination of abdominal wall penetration of stab wounds to the torso, one of which is shown in the diagram below. Patients with penetrating abdominal trauma generally require complete laboratory profiles in case of need for emergent operation. Many imaging modalities can be useful in the evaluation of a patient with penetrating abdominal trauma. The imaging needs of each patient differ, depending on hemodynamic stability and associated injuries. Blood and Urine Studies In case of need for emergent operation, all patients with penetrating abdominal trauma should undergo certain basic laboratory testing, as follows: Blood type and crossmatch Complete blood count (CBC) Electrolyte levels Blood urea nitrogen (BUN) and serum creatinine level Glucose level Prothrombin time (PT)/activated partial thromboplastin time (aPTT) Venous or arterial lactate level Calcium, magnesium, and phosphate levels ... Plik z chomika: cleare Inne pliki z tego folderu: 04.MPG (34154 KB) 16.MPG (49228 KB) 11.MPG (51212 KB) 07.MPG (43178 KB) 10.MPG (31960 KB) Inne foldery tego chomika: Zgłoś jeśli naruszono regulamin Strona główna Aktualności Kontakt Dla Mediów Dział Pomocy Opinie Program partnerski Regulamin serwisu Polityka prywatności Ochrona praw autorskich Platforma wydawców Copyright © 2012 Chomikuj.pl badanie fizykalne filmiki ANG chirurgia Dokumenty Galeria lep kursy