injuries poisoning
Overview of Abdominal Trauma
Treatment of Abdominal Trauma
Sometimes laparotomy for hemorrhage control, organ repair, or both Rarely arterial embolization Patients who appear to be in hemorrhagic shock should receive damage control resuscitation until hemorrhage can be controlled. Damage control resuscitation uses blood products in an approximately 1:1:1 ratio of plasma to platelets to packed red blood cells to minimize the use of crystalloid solutions ( Treatment reference ). A target systolic blood pressure of > 100 mm Hg during resuscitation while awaiting definitive management of hemorrhage is ideal. Crystalloid intravenous fluid can be given as a last resort if no blood products are available. With a lack of clotting factors, inability to carry oxygen, and a low pH, crystalloid intravenous fluids contribute to acidosis and coagulopathy in patients with hemorrhagic shock. Some hemodynamically unstable patients are taken for immediate exploratory laparotomy as described above. For the majority of patients who do not require immediate surgery but who have intra-abdominal injuries identified during imaging, management options include observation, angiographic embolization, and less frequently operative intervention. Prophylactic antibiotics are not indicated when patients are managed without surgery. However, antibiotics are often given before surgical exploration. Observation (beginning in an intensive care unit [ICU]) is often appropriate for hemodynamically stable patients with solid organ injury, many of which heal spontaneously. Patients with free fluid seen during CT but no specific organ injury identified may also be observed provided they have no peritoneal signs. However, free fluid without evidence of solid organ injury is also the most frequent radiographic finding in hollow viscus injury, although this finding has low specificity. Because observation is not appropriate for hollow viscus perforation (patients typically develop Sepsis and Septic Shock due to peritonitis), clinicians should have a lower threshold for operative exploration when patients with isolated free fluid worsen or fail to improve during a period of observation. During observation, patients are examined several times per day (preferably by the same examiner), and a complete blood count (CBC) is done, typically every 4 to 6 hours. Assessment seeks to identify ongoing hemorrhage and peritonitis. Ongoing hemorrhageis suggested by Worsening hemodynamic status Significant ongoing transfusion needs (eg, more than 2 to 4 units over a 12-hour period) A significant decrease in hematocrit (Hct; eg, by > 10 to 12 percentage points) The significance of transfusion requirements and change in Hct depend somewhat on the organ injured and other associated injuries (ie, that may also have caused blood loss) as well as the patient's physiologic reserves. However, patients suspected of significant ongoing hemorrhage should be considered for angiography with embolization or immediate laparotomy. requires further investigation by How To Do Diagnostic Peritoneal Lavage (DPL) (DPL), CT, or in some cases, exploratory laparotomy. Patients who remain stable are typically transferred to a regular floor after 12 to 48 hours, depending on the severity of their abdominal and other injuries. Their activity and diet are advanced as tolerated. Typically, patients may be discharged home after 2 to 3 days. They are instructed to restrict activity for a minimum of 6 to 8 weeks. It is not clear which asymptomatic patients require an imaging study before resuming full activity, especially when heavy lifting, contact sports, or torso trauma are likely to occur. Patients with high-grade injuries are at the highest risk for postinjury complications and should have the lowest threshold for repeat imaging. Laparotomy is selected either because of the initial nature of the injury and clinical status (eg, hemodynamic instability) or because of subsequent clinical decompensation. Most patients can have a single procedure during which hemorrhage is controlled and injuries repaired. However, patients with extensive intra-abdominal injuries who undergo a prolonged initial surgical procedure tend to fare poorly, particularly when they have other serious injuries, have been in Shock for a prolonged period, or both. The more extensive and lengthy the initial surgical procedure, the more likely such patients are to develop the highly lethal combination of acidosis, coagulopathy, and hypothermia with subsequent multiple organ dysfunction. In such cases, mortality can be lessened if the surgeon initially does a much briefer procedure (termed damage control surgery) in which the hemorrhage and enteric spillage are controlled (eg, by packing, ligation, shunting, oversewing, or stapling bowel) without definitive repair and the abdomen temporarily closed. Temporary closure can be achieved using a closed suction vacuum system constructed from towels, drains, and large bio-occlusive dressings or through use of a commercially available negative-pressure abdominal dressing. Patients are then stabilized in the ICU and taken for packing removal and definitive repair once normal physiology has been restored (particularly correction of pH and temperature), typically within 24 hours—or sooner if they deteriorate clinically despite resuscitation. Because patients requiring damage control procedures are the most seriously injured, mortality is still significant and subsequent intra-abdominal complications are common. Ongoing bleeding can sometimes be stopped without surgery by embolizing the bleeding vessel using a percutaneous angiographic procedure (angiographic embolization). Hemostasis is obtained by injecting a thrombogenic substance (eg, powdered gelatin) or metallic coils into the bleeding vessel. Although there is not complete consensus, generally accepted indications for angiographic embolization include Pseudoaneurysm Arteriovenous Fistula None Solid organ injury (particularly of the liver) or Pelvic Fractures with bleeding severe enough to require postresuscitation transfusion Angiographic embolization is not recommended for unstable patients because the radiology suite is a suboptimal area for providing critical care. Additionally, prolonged attempts at embolization should be discouraged in patients whose bleeding requires continued transfusion; operative management is more appropriate. However, with increasing availability of hybrid operating suites (operating room with angiographic intervention capabilities), some unstable patients may be able to undergo angiography and surgical management in rapid succession if needed. Holcomb JB, Tilley BC, Baraniuk S, et al: Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma.JAMA313(5):471-482, 2015. doi: 10.1001/jama.2015.12 