ABDOMINAL TRAUMA

 

219. ABDOMINAL TRAUMA

PATOPHYSIOLOGY

1. Blunt Trauma

  mechanism : 1) the direct  blow

                2) crush

                3) the deceleration injury --> renal pedicle

                                                aorta at ligamentum arteriosum

                                                trachea at the carina

2. penetrating injuries

  1) stab wounds

  2) gunshot wounds   ㄱ. direct missile penetration of tissues

                       ㄴ. missile fragmentation

                       ㄷ. "shock waves" transmitted to neighboring orhan

CLINICAL FEATURES OF SPECIFIC ORGAN INJURY

1. Hollow Organs

   organ contents내의  bacterial flora가 peritoneal cavity를 자극하여 peritonitis를

   일으킨다.  --> DPL이 가장 좋은 진단방법이다.

2. Stomach

   resistat to blunt trauma

   nasogastric tube --> heme positive시 의심

3. duodenum

   retroperitoneum  --> 진단의 어려움

   retroperitoneal air & serum amylase level의 상승

4. Small bowel

   similar to stomach injures

   deceleration injury --> antimesenteric border

5. colon

   management is controversal

   rt. side lesion --> repaired primarily

   lt. side lesion with extensive contamination --> colostomy

6. rectum

   rectal palpation --> stool for blood

                         bony fragmentation with pelvic fracture

                         prostate의 상방전위시는 urethral injuries를 의심

   management --> preop. broad spectrum antibiotics.

                      repair of associated injuries

                      drainage

                      fecal diversion  :  end-on proximal sigmoid colostomy

                                          washout of the distal rectum

7. Gall bladder and biliary ducts

   most frequently as a result of penetrating trauma

   DPL --> positive for bile

8. genitouribary tract

   gross hematuria  -->  cystogram

                            IVP

9. Liver

   commonly injured in both blunt and penetration trauma

   most injuries are self - limited

   T3-15

Blunt liver injury

 Class I : capsular tears, laceration < 1cm

 Class II : Laceration 1-3cm

 Class III : subcapsular hematomas < 10cm

            deep or stellate fractures

 Class IV : Large subcapsular hematomas

            extensive parenchymal damage

 Class V : Crush injuries with bilobar damage

           avulsion hepatic vein injuries

10. spleen

   Sx ;  1) blood loss with tachycardia, hypotension, syncope

         2) Kehr's sign

         3) Left shoulder - strap pain

   T3-14

11. pancreas

   most common with penetrating trauma

   the exocrine products --> irritative effect on the peritoneum

12. kidney

 

   T3-16  

E.D EVALUATION

1. Laboratory

   1)hematology

   2)serum amylase, lipase, and pancreatic isoenzyme

            ;  lack sensitivity and specificity

   3)liver functions

   4)serum bicarbonate

2. DPL

 장점  :  sensitivity ( 98% ) but relative lack of specificity

          availability

          ralative speed

   T7-3

   T7-4

   T7-5

3. CT scan

  1) advantage  ;  specificity  -->  solid organ

                    retroperitoneum

  2) disadvantages  ;  inaccuracies   --> falsely negative for hollow injuries

                        complications  --> aspiration of oral contrast

                                             and allergic reactions of contrast

4. Ultrasonography

                         

TREATMENT

  Ix for exploratory celiotomy

  a. abdominal trauma and hemodynamic instability

  b. abdominal wall disruption with evisceration

  c. clinical finding of peritoneal irritation

  d. free air in abdominal on x-ray

  e. retroperitoneal air on x-ray

  f. ruptured urinary bladder ( intraperitoneal )

  g. positive peritoneal tap or lavage

  h. rectal perforation

  I. surgically correctable lesions suggested by CT scan

221. TRAUMA TO THE GUT

    :Basic process of obtaining

     - a pt HX, performing a P/EX, examining the urine,

     - interpreting radiographic imaging : essential for accurate DX & TX.

  (A) PERINEAL INSPECTION DURING THE SECONDARY SURVEY

     (1) INSPECT THE PERINEUM

        @ Bl on the underwear

          -importing finding

        @ search of perineal laceration

          -usually denote an open pelvic Fx

          -start antibiotics ; 2세대 cephalosporin(cefoxitin) 2g IV

     (2) RECTAL EXAMINATION

        @ noting

          -sphincter tone, the position & quality of the prostate gl, whether or not bl is             present in the rectum.

        @ Bl in the rectum

          :signify rectal perforation→ srart antibiotics

        @ ↓sphincter tone

          : mean spinal cord injury

            *sacrum Fx (+) ; signify a cauda equina syndrome

         @ prostate

          : riding high or boggy feeling→ disruption of the membranous urethra

     (3) PALPABLE THE SCROTUM

         @ checking for eccymosis, laceration & testicular disruption

         @ papable the length of the penis

         @ in female : inspect the labia looking for laceration

      (4) BIMANUAL VAGINAL EXAM

          @ vaginal laceration (+) : start antibiotics

      (5) PELVIC FX

          (+) : important implication in the workup for GU injuries.

(B) RADIOLOGIC EVALUATION

   (1)KUB (plain film, scout film)

     *stone과 DDX해야할 calcification

      -mesentery L/N의 석회화

      -phlebolith (정맥석)

      -arterial plaque

      -renal cyst, renal ca, adrenal, liver, pancreas, spleen의 석회화상.

   

  (2) UROGRAPHY(요로조영술)

     ♠INTRAVENOUS PYELOGRAPHY :IVP  (excretory urography) 경정맥성(배설성)

       @방법

         :-조영제를 IV, SC, IM후 조영제가 신으로 배설되는 것을 방사선으로 촬영.

          -대개, IV후 3-5분, 10-15분, 25분에 각각 1매씩 supine position에서촬영.

          -배뇨후 재촬영시 잔뇨의 유무도 알 수 있다

     ♠RETROGRADE PYELOGRAPHY

       @방법

         :cystoscophy와urine cath가 필요한 비교적 invasive한 방법으로 조영제를

          u-cath를 통해 ureter와 renal collecting system에 주입하여 촬영.

       @ IX

         :IVP에서 collecting sys이 선명히 나타나지 않을 때

       @단점

         :IVP에 비해 형태적인 변화는 잘 알수있으나,신기능을 알수없다

    (3) CYSTOGRAM (방광조영술)

        @ IX

          :내시경검사가 불가능하거나 내시경검사로 결정할 수 없는 변화에 대해검사.

           VU-REFLUX, Bladder rupture, Diverticulitis

        @종류

         1)Excretory cystogram (Washout film) ;배설성 방광조영술

           -방법 :IVP시 상부요로의 촬영이 끝난즉시 300-500ml의 물을 먹이고 30-60분후                    에 촬영

           -IX   :urethral injury, BPH, bladder ca

         2)Retrograde cystogram

            -방법 :contrast sol(adult;400-500ml, children;5ml/kg)을 방광에 cath를 삽입

                   하여 2ft(60cm)높이에서 중력으로 주입후 촬영

                    .높은농도의 조영제사용;UB의 크기,형태,게실,천공,누공,방광요관역류를

                                          알기위해

                    . 낮은 “        ”      ;종양

          3)Voiding cystourethrography

            -방법  ;retrograde cystogram과 동일.

            -IX    :방광요관역류, 후부요도판막진단

     (4)RETROGRADE URETHROGRAM

         @방법

           :F-cath를 요도에 1-2cm삽입하고 ballon(1ml of saline)을 fossa navicularis에서

            팽창시킴 →약 30cc의 radiocontrast sol을 inj.

         @ IX

           :-when bl is found at the urethral meatus

            -penile, bulbous, membranous urethra의 변화를 잘 나타내줌

             그러나 외요도괄약근과 방광경부 때문에 prostatic urethra의 변화는 잘 나타               나지 못함.→배뇨중 요도조영술에서 더 잘 나타남.

      (5)ENHANCED ABDOMINAL CT

        :-In the multiply injured pt in stable condition,in the initial study.

         -ASSESS .associated abdominal injuries

                   . to stage the extent of renal injury

(C) RENAL INJURY

    :-M/frequent form of GU-trauma

     -복강내 다른장기의 손상이 약 80%에서 동반됨

    @분류

      1) minor renal injury   : concusion, subcapsular hematoma,

                               simple laceration(collecting sys과 연결되지 않음)

      2) major renal injury   : renal laceration→ perirenal hematoma formation

                                deep laceration (collecting sys과 연결되는 심한 신실질                                                   (의 열상.

      3) critical renal injury  : renal rupture, renal pedicle injury,신실질의 광범위한손상

   

    @Penetrating renal injury

      -stab wound      ;한국

      -gunshot wd      ;서양

    @Blunt renal injury

      -80-85%

      -TA              ;한국

      -IX for radiographic evaluation

       :Fx rib, vertebral trans-proc Fx, flank bruises or hematomas & hematuria

 (1) RENAL CONTUSION

    @Incidence    : 92% of nenal injury

    @DEF    : minor renal injuries with renal parenchymal ecchymosis,

                                         minor laceration,

                                         subcapsular hematoma with an intact renal                                              capsule.

      @RADIOGRAPHICALLY

        :-IVP ;usually normal

         -CT ;renal edema with microextravasation of contract within the renal                         parenchyme.

      @TX

        :-conservatively with bed rest

          . pt with gross hematuria  ; BR until the gross hematuria resolves

          . limited activity until be microscopic hematuria resolves

         -hydration

      @PX

         :almost always resolve without sequelae unless there is a preexisting renal

          lesion such as hydronephrosis, cyst, or tumor.

 (2) RENAL LACERATION

    :@INCIDENCE

      :5% of renal injury

     @CLASSIFI

       -medullar or collecting sys을 involve하지않은 minor cortical laceration.

       -corticomedullary junction or collecting sys속으로 깊숙이 extend 한 major renal

        laceration.→hematoma may fill the perirenal space.

     @RADIOGRAPHIC

      -disruption of the renal outline

      -perirenal hematoma

      -KD주위로 조영제의 extrvasation이 가능.

    @TX

      :controversial

      1)minor laceration  ;without sequelae with conservative Tx

      2)major laceration  ;-may develop CX.

                          -stable hemodynamic condition with conservative Tx.

      3)surgical exploration

         -absolute IX  ;persistent retroperitoneal bleeding with hemodynamic instability.

         -relative  IX  ;include stable pt with .extensive urinary extravasation,

                                              .large devitalized renal fragment

                                              .renal pedicle injury

(3) RENAL RUPTURE

   @INCIDENCE

    : 1% of renal injury

   @DEF

     -renal rupture를 동반한 large expanding perirenal hematoma.

     -clinically unstable from the continued bleeding.

   @RADIOGRAPHIC

    : devitalized KD fragments

   @TX of choice

    : renal exploration with preliminary pedicle control with vascular clamps &                 nephrectomy.

(4) RENAL PEDICLE INJURY.

   @INCIDENCE

     :2% of all renal injuries.

   @INCLUDE

     :laceration & thrombosis of the renal a,v & their br.

     *blunt injury에서 M/C renal pedicle injury

      ;adventitial과 med layer가 intact 하고 intima의 tearing으로인한 renal a thrombosis

   @DX

     -bruising surrounding the renal a.

     -no perirenal hematoma.

     -IVP : renal a 가 occlued or divided

     -CT : nonenhanced KD with minimal pph enhancement from the renal capsular                  vessel(Rim sign)

   @TX

     1)nephrectomy            :safest surgical option

     2)repair            :isolated renal pedicle injury를 동반한 stable condition에서                                    injury받은후 12시간내 undertaken.

     3)excised with an end-to-end anastomosis  :intimal tears of the renal a.

     4)repaired by direct suture   : laceration or rupture of the renal v.

     5)thrombosis of segmental arteries  : conservatively.

 (5) RENAL PELVIS RUPTURE.

   @INCIDENCE

     : rare

   @RESULT IN

     : extravasation of urine into the perirenal space & along the psoas m.

   @RADIOGRAPHIC

     :-NL functioning KD.

      -filling of the calyceal sys.

      -extravasation of contrast without visualization of the ureter.

   @DX

     :-retrograde pyelogram  :CONFIRMED.

      -만일 진단이 지연되면;.

      develps high fever, ↑abdo pain, tenderness

      as the extravasation of urine continues into the retroperitoneal space.

(D)URETERAL INJURY (요관손상)

   :rarest of all GU injury from ext trauma.

    (∵)요관은 탄력성과 가동성을 가진 가는 관으로 후복막 깊숙이 숨어있는 까닭에 외력에

    의한 손상이 드믈다.

   (1)원인

     1)외력성 손상   :총상,자상,둔상

     2)외과적 손상   :수술, 내시경조작

    (2)증상

     *수술중 -요관이 부분, 완전 결찰 :술후 고열,측복부나 하복부통증,오심,구토, 장폐쇄

             -양측 요관이 결찰       :무뇨

    (3)dx

      -IVP :손상신의 불현신

    (4)TX

       surgical repaired with wide debridement & ureterouretostomy

        *minor injury :자연치유되거나, 요관카테터유치.

 (E) BLADDER INJURY

    -2ND M/C injury to the GUT after renal injury.

    -UB가 비어있는 경우  :UB가 치골뒤에위치하여 보호를 받음

     UB에 요가충만된 경우:치골상부로 팽창해 UB벽이 얇아지므로 외력으로 쉽게파열됨.

    -복막내파열을 암시 :하복부에 압통이 있으면서 복벽에 강직과 팽만이 있다.

      복막외파열        :치골상부에 압통이있고 종창과 종물이 만져짐.

    -usually asso with blunt trauma, pelvic Fx.

    -penetrating bladder : often asso with injuries to other abd & pelvic organ.

 (1) BLADDER CONTUSION

   1)DEF

    :bruising of the bladder wall with hematuria.

   2)원인

    :주로 골반내수술, 분만, 경요도적기계조작, 하복부충격등 가벼운외상을받았을 때

   3)진단

     cystogram:- intact bladder outline

               - with a fractured pelvis, a large hematoma→displacement of the bladder

                                                            superiorly & laterally

   4)TX

     :conservative

      pt 자신이 배뇨를못하는 경우 카테터를 약 5-7일 유치