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
:
[email protected]
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
•5
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
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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
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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.
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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
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Blunt Abdominal Trauma
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Penetrating Abdominal Trauma : Stab Wound
Abdominal Evisceration
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Penetrating Abdominal Trauma : Gunshot Wound
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Gunshot Wound (machine gun)
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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
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Primary Survey
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Monitoring : Vital sign, ECG,CVP
Adjuncts to Primary Survey
NG tube placement Foley catheter placement
DPL, FAST Radiograph Laboratory examination
• History :
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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
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Spesific diagnostic examination : X-rays,
Adjuncts to Secondary Survey
CT scans,
Urography, Angiography, USG, Bronchoscopy, Esophagoscopy,and etc
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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)
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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 patient’s position in the vehicle, and status of passengers
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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
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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
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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.
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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
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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.
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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)
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In the upright position, blood is visible dependently in the pleural space
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DIAGNOSTIC STUDIES DPL (Diagnostik Peritoneal Lavage) FAST (Focused Assessment Sonography in Trauma) CT (Computed Tomography)
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DPL (Diagnostic Peritonial Lavage)
Indications for DPL in blunt trauma include:
1.
Change in sensorium—Brain injury, alcohol intoxication, and use of illicit drugs
2.
Change in sensation—Injury to spinal cord
3.
Injury to adjacent structures—Lower ribs, pelvis, lumbar spine
4.
Equivocal physical examination
5.
Prolonged loss of contact with patient (anticipated—General 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.
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DPL Absolute contraindication: an existing indication for laparotomy Relative contraindications : previous abdominal operations,
morbid obesity, advanced cirrhosis, and preexisting coagulopathy
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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
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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 Ringer‘s 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.
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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.
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FAST
at least 250 ml of fluid must be present before it can be reliably detected by FAST
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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.
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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.
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Blunt abdominal trauma with liver laceration.
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Blunt abdominal trauma. Right kidney injury with blood in the perirenal space. Injury resulted from a high-speed motor vehicle collision.
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DPL Versus FAST Versus CT in Blunt Abdominal Trauma
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DEFINITIVE MANAGEMENT
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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
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LAPAROTOMY Acces & Exposure Homeostasis – Resection– Reconstruction Damage Control Surgery
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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
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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.
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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
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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
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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
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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
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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.
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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.
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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.
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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.
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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.
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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)
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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
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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
