•          A CASE PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON ABDOMINAL VASCULAR INJURY

                Roberto N. Gonzales Jr., M.D.

                Ospital ng Maynila Medical Center

                Department of Surgery

General Data:

C.M.

34–year-old

Female

Tondo,Manila

Chief Complaint:

Blunt Abdominal trauma

•          HISTORY OF PRESENT ILLNESS

                NOI:       vehicular accident

                TOI:        8:00 pm

                DOI:       04/15/08

                POI:       Pier south

                45 minutes PTC

                                Patient was allegedly hit by a passing vehicle and was thrown to a distance.

                                 Patient was then brought to our institution.

•          Past Medical History

•          No hypertension

•          No diabetes

•          No PTB

•          No previous hospitalization

•          No allergies to foods and drugs

•          Family History

•          unremarkable

•          Personal and Social History

•          unremarkable

•          ABC’s of Trauma

•          Physical Examination

•          General Survey:

–        Conscious, coherent, not  in respiratory distress

•          Vital Signs

BP = 80/ 50  ----- 90/60

CR = 120 bpm    

RR = 23 cpm     Temp: 37’C

•          Physical Examination

•          HEENT:

- Anicteric sclera, pale palpebral conjunctivae,  no NAD, no TPC, no CLAD

•          Chest:

–        Symmetrical chest expansion, no retractions,

–        CBS

•          Physical Examination

–        Heart

                                Tachycardia, regular rhythm, no murmur

•          Abdomen

                                (+) Abrasion RLQ,

                                Firm, tender all quadrant

•          Physical Examination

•          Extremities:

•          Equal pulses, no deformities, no cyanosis

•          Salient Features

•          34/female

•          Hx of Blunt abdominal injury

•          80/ 50  ----- 90/60

•          Tachycardic

•          (+) abrasion RLQ,

•           Firm, tender all quadrant

                         hypotension

                                                                 tenderness

•          Initial Impression

•          Para clinical Diagnostic Procedure

•          Do I need to perform a Para clinical diagnostic procedure?

“No”

•          Pre-treatment Diagnosis

•          Pre Treatment Diagnosis

•          GOALS OF TREATMENT

•          Exploration

•          Control of hemorrhage

•          Prevent exsangiunation

•          Identification and repair of injury

•          Management

Exploratory Laparotomy

•          Preoperative Preparation

•          Informed consent

•          Provide psychosocial support

•          Optimize patient condition

–        Hydration

–        Transfusion of 1 u’ FWB

–        ATS 6000 units TIM   ( ) ANST

–        TT 0.5 ml TIM

–        Operative technique

•          Patient in supine position under GETA

•          Asepsis and antisepsis techniques done.

•          Sterile drapes placed.

•          Midline incision down to the peritoneum.

•          Evacuation of hemoperitoneum

•          Intraoperative findings noted.

•          Operative Findings

•          Midline Retroperitoneal hematoma

                (Zone I inframesocolic)

•          Zone II, III, IV intact

•          No hollow viscus perforation

•          Normal liver and spleen

•          Operative technique

•          Exposure

•          Retroperitoneal hematoma explored.

Right medial viceral rotation

•          Operative technique

•          Injury (laceration) to the infrarenal Inferior vena cava

•          Transection of lumbar veins right

•          Exposure

•          inframesocolic Zone 1

–        control of IVC using

rolled pack and

Babcock clamps

•          Treatment Options

•          Operative technique

•          Lateral venorrhapy using prolene 4-0

•          Ligation of transected lumbar veins

•          Final exploration of all quadrant and contained solid and hollow viscera

•           Adequate peritoneal washing with warm saline

•           Layer by layer closure

•           Sterile dressing applied

•          Final Diagnosis

Blunt Abdominal Injury sec to Vehicular Accident

Hemoperitoneun

Infrarenal Inferior Vena Caval Injury

Transection of lumbar veins

   s/p Exploratory Laparotomy

Evacuation of Hemoperitoneum

Repair of caval injury,

Ligation of lumbar veins

•          COURSE IN THE WARD

•          1^st post operative Day

–        NPO

–        Antibiotic

–        Adequate Analgesia

–        Skeletal survey was negative

–        Labs

•          Hemoglobin – 7.1 mg/dl

–        Transfuse 4 u’ PRBC properly typed and crossmatched

•          COURSE IN THE WARD

•          2^nd-3^rd post operative Day

–        GL- Soft diet

–        Post BT hemoglobin – 10.3 mg/dl

•          COURSE IN THE WARD

•          4^th – 7th post operative Day

–        DAT

–        Adequate Antibiotic

–        Adequate Analgesia

–        DWC

•          COURSE IN THE WARD

•          10th Hospital Day

–        Patient discharged

•          PREVENTION AND HEALTH PROMOTION

•          Advise given to patient regarding

–        Possible complications

–        Proper wound care

–        OPD follow up after 7 days for removal of sutures

•          Outcome:

•          Live patient

•          No complications

•          Satisfied patient

•          No medico-legal suit

•          SHARING OF INFORMATI0N

•          Blunt Abdominal Trauma

 Newton said..

                                “ For every action (force) there is an equal and opposite reaction”

 - When two object of equal velocity strike each other their velocities are reduced to zero and the force is transferred back to each other in the form of energy.

•          This basic law applies to the trauma patient who absorbs the kinetic energy of a projectile or an oncoming automobile

•          The transfer of energy and application of forces in blunt trauma is frequently much more complex than that of penetrating trauma.

•          blunt trauma is associated with multiple widely distributed injuries, whereas in penetrating wounds the damage is localized to the path of the bullet or knife

•          more energy is transferred over a wider area during blunt trauma than from a gunshot wound (GSW) or stab wound (SW).

•          Clinical Presentation

•          Geographic Zones

Zone 1        midline 

                retroperitoneum

•          Supramesocolic

–        supracoeliac aorta

–        coeliac axis

–        prox. SMA

–        prox. renal artery

–        SMV

•          Inframesocolic

–        infrarenal aorta

–        infrahepatic IVC

•          Geographic Zones

Zone 2      upper lateral 

                 retroperitoneum

•          renal artery and vein

•          Geographic Zones

Zone 3         pelvic 

                retroperitoneum

•          common, external, internal arteries and veins

•          Geographic Zones

Zone 4   porta hepatis 

•          portal vein

•          hepatic artery

•          retrohepatic IVC

•          Operative Management

GENERAL PRINCIPLES

•          Zone 1                  penetrating/blunt   → open

•          Zones 2,3,4         penetrating            → open

•          Zones 2,3,4         blunt                         → open only

                                                                                if… pulsatile

                                                                                       rapidly expanding

                                            ruptured

•          Endovascular Management

ADVANTAGES

•          delineate specific site of injury without surgical exploration

•          provides rapid vascular control

•          enables definitive repair despite presence of contamination

•          Avoidance of aortic cross-clamping, which can lead to varying periods of visceral ischemia,hepatic hypoperfusion, and the resultant fibrinolytic state

•          Local Experience

•          3-year single center, retrospective review

•          Results:

–        22 pts, 24 vessels injured

–        mean age: 30

–        penetrating in 100% of cases

•          SW                         73%

•          GSW      27%

•          Local Experience

•          Outcome

–        86% survival

                (19/22)

–        3 deaths (all due

exsanguination)

•          Journal Appraisal

                Enteral Versus Parenteral Feeding

                Effects on Septic Morbidity After Blunt and Penetrating Abdominal Trauma

•          KENNETH A. KUDSK, M.D.,et. Al.

•          Departments of Surgery, Clinical Pharmacy, and Biostatistics and Epidemiology, Presley Memorial Trauma Center

•          University of Tennessee, Memphis

•          Objective

•          To investigate the importance of route of nutrient administration on septic complications after blunt and penetrating trauma.

•         
Design:

•          randomized prospective study

•         
Setting:

•          Presley Memorial Trauma Center at the University of Tennessee,Memphis.

•         
Patients:

•          Ninety-eight trauma patients admitted to the Presley Memorial Trauma Center at the University of Tennessee,Memphis, requiring an emergent laparotomy between December 1989 and August 1991 were enrolled in thestudy protocol.

•         
Intervention:

•          Enteral Versus Parenteral Feeding.

•         
Main outcome measures:

•          septic morbidity rates

•         
Results:

•          Conclusion

•          There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma, with most of the significant changes occurring in the more severely injured patients.

•          Recommendation

•          The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients, particularly in the most severely injured patients.

Appraisal Guide

•          Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.

•          patients were assigned to either ENT or TPN feeding using a randomization table generated by computer before institution of the study.

•          Are the results of the study valid?

Primary Guides:

2.  Were all patients who entered the trial properly accounted for and attributed at its conclusion?

yes.

•          Ninety-eight patients entered the study.

•          One death occurred within 4 days in each of the groups due to hemodynamic instability and progressive multiple system organ failure.

•          Groups were well matched for severity ofinjury, age, and mechanism of injury

•          Are the results of the study valid?

Secondary Guides:

 3. Were patients, their clinicians, and study personnel "blind" to treatment?

yes.

•          The charts of  the patients were reviewed by a second surgeon blinded to therapy and this determination was considered definitive for the presence or absence of infection.

•          Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

yes.

•          Although trauma patients cannot be considered a homogeneous population, they have in common a hypermetabolic response to injury, acute deterioration in lean body mass, and a high rate of septic complications.

•          Are the results of the study valid?

Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

yes.

•          Perioperative broad-spectrum antibiotics were administered prophylactically to all patients for no more than 5 days

•          Are the results of the study valid?

Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

yes.

•          Pharmacy provided a parenteral formula with similar concentrations of protein, carbohydrate, and fat to that of enteral formula

•          Are the results of the study valid?

Secondary Guides:

6. Overall, are the results of the study valid?

yes.

•          Guide Questions

•          What are the results?

1. How large was the treatment effect?

•          There is a significantly lower incidence of septic morbidity in patients fed enterally than parenterally

•          Guide Questions

•          What are the results?

1. How large was the treatment effect?

•          Use of TPN was associated with a sevenfold increase in the risk of infection, with an incidence of 11.1% (3/27) with ENT feeding versus 47.6% (10/21) with TPN (p < 0.005).

•          Guide Questions

•          Will the results help me in caring for my patients?

1. Can the results be applied to my patient care?

•          Patients may have enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients, particularly in the most severely injured patients.

•          Research

•          Will the results of my study be valid?

–        randomize

–        all patients accounted for

–        “Blind”

–        the groups similar

–        the groups treated equally

•          What will be the results?

•          Will the results help others in caring for their patients?

•          Questions

#1 Hematoma or hemorrhage in the midline supramesocolic area of zone 1 is cause to suspect the presence of an injury to the following except?

1. suprarenal aorta
2. celiac axis
3. superior mesenteric artery
4. Suprahepatic venacava

•          Questions

#1 Hematoma or hemorrhage in the midline supramesocolic area of zone 1 is cause to suspect the presence of an injury to the following except?

1. suprarenal aorta
2. celiac axis
3. superior mesenteric artery
4. retrohepatic venacava

•          Questions

#2 Injury to the renal artery, the renal vein, or the kidney fall in what zone?

1. Zone I
2. Zone II
3. Zone III

d.  Zone IV

•          Questions

#2 Injury to the renal artery, the renal vein, or the kidney fall in what zone?

1. Zone I
2. Zone II
3. Zone III

d.  Zone IV

•          Questions

#3 Left medial visceral rotation will expose the following except?

1. Celiac axis
2. Proximal SMA
3. Suprarenal aorta
4. retrohepatic venacava

•          Questions

#3 Left medial visceral rotation will expose the following except?

1. Celiac axis
2. Proximal SMA
3. Suprarenal aorta
4. retrohepatic venacava

•          Questions

MCR

(a = 1,2,3; b = 1,3; c = 2,4; d = 4 only; e = all)

•          Questions

#4 (MCR) With regards to IVC exposure, which of the following statements are true?

1. The infrahepatic IVC can be exposed by means of right medial visceral rotation.
2. The portion of the IVC immediately below the liver can be exposed by performing the Kocher maneuver.
3. Access to the suprahepatic IVC can be gained by incising the central tendon of the diaphragm
4. Access to the suprahepatic IVC can be gained by performing a median sternotomy and opening the pericardium.

•          Questions

#4 (MCR) With regards to IVC exposure, which of the following statements are true?

1. The infrahepatic IVC can be exposed by means of right medial visceral rotation.
2. The portion of the IVC immediately below the liver can be exposed by performing the Kocher maneuver.
3. Access to the suprahepatic IVC can be gained by incising the central tendon of the diaphragm
4. Access to the suprahepatic IVC can be gained by performing a median sternotomy and opening the pericardium.

•          Questions

# 5 The following is/are true regarding Zone I Inframesocolic area.

1. The lower area of the midline retroperitoneum
2. Exposure is best achieved by means of left medial visceral rotation
3. Injuries to either the infrarenal abdominal aorta or the inferior vena cava occur.
4. Kocher maneuver is not necessary for exposure.

•          Questions

# 5 The following is/are true regarding Zone I Inframesocolic area.

1. The lower area of the midline retroperitoneum
2. Exposure is best achieved by means of left medial visceral rotation
3. Injuries to either the infrarenal abdominal aorta or the inferior vena cava occur.
4. Kocher maneuver is not necessary for exposure.

•          Questions

#6 The following is/are true regarding Zone II retroperitoneal hematoma management

1. suspect the presence of injury to the renal artery, the renal vein, or the kidney.
2. Nephrectomy should be performed if ligation of the right renal vein is necessary to control hemorrhage
3. medial left renal vein may be ligated as long as  left adrenal and gonadal veins are intact.
4. If there is active hemorrhage from the kidney central renal vascular control is necessary.

•          Questions

#6 The following is/are true regarding Zone II retroperitoneal hematoma management

1. suspect the presence of injury to the renal artery, the renal vein, or the kidney.
2. Nephrectomy should be performed if ligation of the right renal vein is necessary to control hemorrhage
3. medial left renal vein may be ligated as long as  left adrenal and gonadal veins are intact.
4. If there is active hemorrhage from the kidney central renal vascular control is necessary.

•          References

•          Schwartz et. al Principles of Surgery.8^th ed. Chapter 6.

•          Abdominal Vascular Trauma

Trauma 5^th edition by Kenneth L. Mattox.

•          ACS Surgery: Principles and Practice   2nd edition by Douglas W., Md. Wilmore

                     Thank you!