Abdominal Injuries At A Glance

The abdomen can be injured by many types of trauma. An injury can be limited to the abdomen or with a severe trauma that affects multiple organ systems associated. Type and severity of abdominal injuries vary widely depending on the mechanism of injury and the forces involved. Thus can be misleading generalizations about mortality and need for surgical intervention.

(See also dealing with trauma patients.) The abdomen can be injured by many types of trauma. An injury can be limited to the abdomen or with a severe trauma that affects multiple organ systems associated. Type and severity of abdominal injuries vary widely depending on the mechanism of injury and the forces involved. Thus can be misleading generalizations about mortality and need for surgical intervention. Injuries are categorized often after the damaged structure: abdomen discussed solid organs (liver, spleen, pancreas, kidney) hollow organ (stomach, small intestine, large intestine, ureter, bladder) vasculature Some specific injury from abdominal trauma are elsewhere such. B. injury of the liver, spleen, and the intestinal tract. Etiology An abdominal trauma is usually categorized by the mechanism of injury: Stumpf penetrating A blunt trauma, a direct blow to be (for example, a kick.), A collision with an object (for example, fall on the bicycle handlebar.) Or be sudden deceleration (z. B. fall from a height, the motor vehicle impact). The spleen is the most frequently damaged organ, followed by the liver and a hollow organ (typically the small intestine). Penetrating injuries may, but do not penetrate the peritoneum, and when it happens, that does not necessarily one organ injury entail. Stab wounds damage rarer than gunshot wounds, the intra-abdominal structures. Both injuries, however, each of the structures can be affected. Penetrating wounds to the lower chest can cross and cause damage to the abdominal structures the diaphragm. Classification injury scales have been developed to classify organ injury to their severity, from Grade 1 (minimal) to classes 5 and 6 (solid); Mortality and need for surgical repair increases with the degree of injury. There are scales to the liver (the degree of liver damage), spleen (severity of injuries of the spleen) and kidneys (severity of renal injury.). Associated injuries A blunt or penetrating injury that affects the intra-abdominal structures can also damage causing the ribs to the spine and / or pelvis. Patients who have experienced a significant deceleration, often have injuries to other parts of the body, including the descending aorta. Pathophysiology blunt or penetrating trauma can injure the intra-abdominal structures or tear. but blunt injuries can also cause only a hematoma in a solid organ or in the wall of a hollow organ. Injuries immediately begin to bleed. Bleeding from a low grade injury of a solid organ, a slight vascular injury or a hollow organ is often a small amount, with minimal physiological consequences. More severe injuries cause massive bleeding with shock, acidosis and coagulopathy (shock); Here intervention is required. Bleeding is here internally (except for relatively small amounts of external bleeding due to lacerations of the body wall, caused by penetrating trauma). An internal bleeding may be intraperitoneal or retroperitoneal. An injury or rupture of a hollow organ causes the stomach, intestine or bladder release their contents into the abdominal cavity, leading to peritonitis. COMPLICATIONS late effects of abdominal injuries are Hämatomruptur intra-abdominal abscess intestinal obstruction or ileus leakage of bile and / or an encapsulated collection of bile into the abdominal cavity Abdominal compartment syndrome abscess, intestinal obstruction, abdominal compartment syndrome, delayed hernia and may also be complications of treatment. Hematomas typically resorb spontaneously over several days to months, depending on the size and location. Hematomas of the spleen and, less commonly, liver hematoma can rupture, often in the first few days after the injury (although sometimes months later), and they can cause significant delayed bleeding. Intestinal wall hematoma can sometimes perforate, typically within 48-72 hours after the injury, with effusion of the intestinal contents and resulting peritonitis, but without major bleeding. Intestinal wall hematoma may have a stenosis until years later usually cause months, in rare cases. However, there are case reports of intestinal obstruction that occur only two weeks after a blunt trauma. Intra-abdominal abscesses are usually the result of an unrecognized Hohlorganperforation, but can also be a complication of laparotomy. The incidence of development of abscesses in the range of 0% to the non-therapeutic laparotomies up to about 10% after therapeutic laparotomies, although the incidence may be as high as 50% after a surgery to repair a crack severe liver. A bowel obstruction often weeks or years after the injury developed by an intestinal wall hematoma or adhesions after intestinal serous or mesenteric tears. More commonly the bowel obstruction is a complication of exploratory laparotomy. Even non-therapeutic laparotomy occasionally cause adhesions, which can develop in 0-2% of cases. Leakage of bile and / or the Biloma is a rare complication of liver damage and even rarer than bile duct injury. Bile can be eliminated from the raw surface of a damaged liver or from an injured bile duct. You can spread throughout the abdominal cavity or encapsulated in a significant accumulation of fluid, called Biloma. A bile leak can lead to pain, systemic inflammatory response and / or hyperbilirubinemia. An abdominal compartment syndrome similar to compartment syndrome in the extremities after orthopedic injuries. An abdominal compartment syndrome, mesenteric and intestinal capillary leaks (eg., By a blow, a prolonged abdominal surgery, systemic ischemic reperfusion injury, or systemic inflammatory response syndrome [SIRS]), tissue edema caused within the abdominal cavity. Although there is more room to expand into the abdominal cavity are as in a limb, an uncontrolled edema or (occasionally), which has a ascites, ultimately increase the Intral-abdominal pressure over 20 mmHg pain, Organischämie and organ dysfunction result. Intestinal ischemia continues to worsen an existing leak in the vessels, which leads to a vicious circle. Other affected organs are kidneys (renal failure causing) lung (increased pressure in the abdomen may impair breathing, which can lead to hypoxemia and hypercapnia) cardiovascular system (increased pressure in the abdomen decreased venous return from the lower extremities, which hypotension leads) CNS (the intracranial pressure may be increased, possibly due to increase central venous pressure, whereby an adequate venous drainage is prevented by the brain, by reducing the cerebral perfusion, which can aggravate intracranial injury) an abdominal compartment syndrome usually occurs at conditions (about 10 l) comes together where a vessel leakage at a high hydration. It often develops after a laparotomy because of a severe abdominal injury, accompanied by a shock. but it can occur even if not directly, the abdomen is affected such. As in severe burns, sepsis and pancreatitis. Once a multi-organ failure has developed, is the only way to save the patient’s life, to decompress the abdominal contents, usually through a laparotomy. A large-volume paracentesis can be effective when a severe ascites present. Symptoms and signs Abdominal pain is usually available, but the pain is often insignificant and therefore easily by other painful injuries (z. B. fractures) or by an altered sensation (z. B. due to a head injury, by drug abuse or shock) covered. Pain due to an injury of the spleen rays sometimes up to the left shoulder. Pain Augrund a small bowel perforation are typically initially minimal, but worsen steadily in the first hours. Patients with renal impairment may notice hematuria. In the investigation of vital functions may an indication of hypovolemia (tachycardia) or a shock give (z. B. dark color, sweating, altered sensorium, hypotension). Inspection Penetrating injuries cause by definition, cracks in the skin, but doctors are strongly recommended to the back, the buttocks, the edges and the lower breast in addition to abdominal investigate, especially when firearms or explosives were involved in the violation. Skin lesions are often small and bleed minimal, although sometimes the wounds are too large, possibly with a stepping out of the intestines. Tips and risks Not all penetrating abdominal injuries come from wounds to the abdominal wall. Doctors should carefully examine the back, buttocks, flanks, the dam and the lower chest. Blunt trauma cause ecchymoses (z. B. transverse linear cutaneous bleeding, which may be from a seat belt), but this finding is not very significant for a diagnosis. An abdominal distention after a traumatic indicated generally severe bleeding (2-3 l) back, but the abdominal distention, even in patients who have lost a lot of blood, not auffallen.Palpation Abdominal pressure pain sensitivity is often present. However, this character is very unreliable, as well as bruising of the abdominal wall will cause pressure sensitivity to pain and many patients with intra-abdominal injuries have misleading results in examinations when they are distracted by other injuries or have an altered sensorium or if their injuries especially are retroperitoneal. Although they are not very accurate, if they are detected, peritoneal signs point (z. B. guarding, security, knocking pain) indicates the presence of intraperitoneal blood and / or gut contents. Rectal examination may reveal a strong discharge of blood, which can result from a penetrating injury of the colon. In addition, blood at the urethral meatus may be present or even a perineal hematoma due to an intestinal tract injury. Although these findings are quite specific, they are not very sensitive. Diagnosis Clinical evaluation The diagnosis is often made by CT or ultrasonography. As with all patients with severe trauma doctors perform a thorough and complete investigation, while resuscitation (s. Approaching the trauma patients). Since many intra-abdominal injuries without special treatment to heal, is the primary goal of the physician to identify the injuries that require treatment. After clinical evaluation a few patients in urgent need of an exploratory laparotomy instead of further tests. These include patients with: peritonitis Hemodynamic instability due to a penetrating abdominal trauma gunshot wounds (most common) leakage of the gut Conversely, a few patients a very low risk and can be fired or they are observed for a short time, with their urine checked for large amounts of blood becomes. These patients have an isolated blunt abdominal trauma and a less violent course of the accident, a normal sensorium and no tenderness or signs of peritoneal dialysis in general. However, they should be advised to return immediately if the pain worse. Patients with isolated anterior abdominal stab wounds that are not penetrated into the fascia can also be seen briefly and released (1). However, most patients do not have such a clear positive or negative findings and therefore need a study on intra-abdominal injuries. To the test options include imaging methods (sonography, CT) study measures such. As an exploration of the wound or diagnostic peritoneal lavage in patients also usually a chest X-ray should be made In addition to check free air under the diaphragm (indicating a perforation of a hollow organ), and an increased diaphragm (suggesting a diaphragmatic rupture points). Radiographs of the pelvis are performed in patients who respond to the pelvis sensitive to pressure and its outcome in the clinical examination was unclear. Into question a radiograph of the pelvis is also performed when the patient has experienced an accident with a strong deceleration. Laboratory tests are secondary. A urinalysis to rule out hematuria, both a strong and a microscopic, is helpful. A complete blood count with a provision of Hämatokritspiegels is also useful in patients with apparent serious injuries. Tests to verify the pancreatic and liver enzymes are not sensitive or accurate enough to reveal important information for patients with organ injuries. The laboratory should undertake a type and screen-determination if a blood transfusion is necessary; the cross matching and blood group determination is made if a transfusion is very likely. Serum lactate or a determination of the base deficit (from the arterial blood gas analysis) can help to discover an occult shock. The method chosen to detect intra-abdominal injuries depends on the mechanism of injury and clinical examination. Penetrating abdominal trauma Blind poking in the wound with a blunt instrument (eg. B. cotton swab, finger tip) should be avoided. If the peritoneum is injured, this type of investigation can lead to infection or cause further damage. Stab wounds (including impalements) at the front abdomen (between the two anterior axillary folds) in haemodynamically stable patients with no evidence of peritoneal dialysis can be analyzed locally. For this purpose, usually used local anesthesia and the wound opened sufficiently to allow a full view of the affected area. If the front fascia has been penetrated, patients are approved for serial clinical examinations; an exploratory laparotomy is performed when showing peritoneal signs or developed hemodynamic instability. When the fascia is not injured, the patient can be discharged after the wound was cleaned and repaired. Alternatively, some centers arrange for a CT or, more rarely, a diagnostic peritoneal lavage (DPL) to assess patients with severed fascia. A CT is recommended for stab wounds in the flank (between the front and rear axillary folds) or behind (between the 2 rear axillary folds) as injuries to the retroperitoneal structures that are below these ranges, are often overlooked in the serial abdominal examination. In gunshot wounds, most doctors perform an exploratory laparotomy, unless the wound is clearly a graze or a glancing blow and it is neither peritonitis nor hypotension before. However, some centers prioritize a non-surgical approach in patients with a single violation of a solid organ (usually the liver) and investigate why stable patients with gunshot wounds rather by CT. A local exploration of the wound usually takes place at gunshot wounds not statt.Stumpfes abdominal trauma in most patients with multiple trauma, and other painful injuries and / or an altered sensorium should be investigated the abdomen, as well as in patients with entsprechden findings in the investigation. Normally examine clinician with ultrasound or CT, sometimes both. A sonography, sometimes called FAST test called (for “focused assessment with sonography in trauma”), can be applied during the initial investigation, without requiring the patient to be transported to radiology. FAST imaging of the pericardium, right and left upper quadrant of the basin and takes place; primary goal is to find abnormal pericardial fluid or intraperitoneal free fluid. An extended FAST (E-FAST) adds images of the breast to detect a pneumothorax. The ultrasound does not cause any radiation exposure and is sensitive enough for the acquisition of large amounts of fluid in the abdominal cavity, but can identify certain injuries to solid organs not very accurate, and helps detect a visceral perforation also no help. In addition, the ultrasound can not be used in severely obese patients and those with a lot of air in the stomach (eg., By a pneumothorax). Advanced Focused assessment with sonography for trauma created (E-FAST) Video of Hospital Procedures Consultants, www.hospitalprocedures.org. var model = {videoId: ‘3903698775001’, playerId ‘SyAEZ6ptl_default’, imageUrl ‘http://f1.media.brightcove.com/8/3850378299001/3850378299001_4412039192001_vs-55c8f388e4b042dbac3ca425-767904725001.jpg?pubId=3850378299001&videoId=3903698775001’ title: ‘Advanced Focused assessment with sonography for trauma (e-FAST)’ description: ” credits ‘video created by Hospital Procedures Consultants, www.hospitalprocedures.org’ hideCredits. true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true}; var panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘video element panel..’); ko.applyBindings (model, panel.get (0)); A CT is usually completed with an i.v. administered contrast agents, this test is very sensitive to free liquid and solid organ injuries, but less accurate for small visceral perforations (but still more accurate than ultrasound), but a CT can incidentally also detect injuries to the spine or pelvis. However, the CT patients, the radiation exposes what has to be considered especially in children and in patients who need to have the repeated examinations (eg. As stable patients with small amounts of free liquid). Another disadvantage is that patients have to be transported for examination out of intensive care in radiology. The choice of a sonography or a CT is performed depending on the patient and his condition. If the patient already needs a CT to examine a different region of the body (eg. As cervical spine, pelvis), the CT is likely to assess the most sensible choice the abdomen. Some doctors also take a FAST test during the resuscitation phase and then go to a laparotomy over when are seen large amounts of fluid (in patients with low blood pressure). If the FAST results are negative or weakly positive, doctors can still cause a CT when concerns exist because of the abdomen after the patient is stabilized. Reasons for these concerns may be increasing abdominal pain, or inability to employ clinical monitoring (eg. As when patients require a strong sedation or lengthy surgical procedures are subjected to). In diagnostic peritoneal a peritoneal dialysis catheter is placed through the abdominal wall near the navel into the pelvic region or the peritoneal cavity. An aspiration of blood is seen as a positive indication of an abdominal injury. If no blood is aspirated, 1 l crystalloid solution is introduced and flushed again. A finding of> 100,000 red cells / ml in the wash liquid is very sensitive to an abdominal injury. However, the DPL has been largely replaced by the FAST test and the CT. The DPL has a low specificity, since they identified many lesions that do not require surgical repair and therefore leads to a high negative incidence in laparotomy. A DPL also overlooks retroperitoneal injury. However, DPL can be useful in certain clinical situations, such. As if there is free fluid in the pelvis and there is no violation of a solid organ or in a patient with low blood pressure and an unclear result after a FAST Test.Erkennen the complications of abdominal trauma in a patient with a sudden worsening of abdominal pain in the days following the injury should be considered a burst solid organ hematoma or a visceral perforation of a hollow organ, in particular when it is found in the patient tachycardia and / or hypotension. A steady worsening of pain within the first day suggests a Hohlorganperforation. Worsening after several days should raise the suspicion of an abscess, especially if the pain of fever and leukocytosis are accompanied. In either case, imaging is caused in stable patients using Sonograhie or CT, followed by a surgical repair. After a serious abdominal trauma an abdominal compartment syndrome in patients with reduced urine output, respiratory insufficiency and / or hypotension should be considered, especially if the stomach is tense or distended (wherein these physical findings, however, does not prove). However, since such phenomena can also be signs of decompensation due to the underlying violations in high-risk patients a high degree of suspicion is required. Diagnosis requires the measurement of the intra-abdominal pressure, usually with a pressure transducer which is connected to the bladder catheter. Values> 20 mmHg are diagnostic of intra-abdominal hypertension and should be considered as worrying. When patients with such symptoms and signs of organ dysfunction (eg. B. hypotension, hypoxia / hypercapnia, decreased urinary output, increased intracranial pressure), a surgical decompression is performed. Normally, the stomach is left open. The wound is temporarily using a vacuum-pack dressing or another association abgedeckt.Hinweis to diagnose Como JJ, Bokhari F, Chiu WC, et al.Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 68 (3): 721-733, 2010. Treatment Sometimes laparotomy for hemostasis, organ repair, or both rare arterial embolization, the patient received an intravenous fluid therapy as needed, usually with crystalloid fluids, either 0.9% saline or Ringer’s lactate solution. But patients in whom a hemorrhagic shock seems to occur should receive resuscitation to limit damage to the bleeding can be controlled. The damage control used resuscitation blood products in a possible ratio of 1: 1: 1 plasma to platelets to red blood cells in order to minimize the use of crystalloid solutions (1). Some hemodynamically unstable patients are being prepared for immediate exploratory laparotomy as described above. For the majority of patients who do not require immediate surgery, but have intra-abdominal injuries that were identified by imaging, are watching, angiographic embolization and, less frequently, a surgical procedure in question. Prophylaxis with antibiotics is not necessary if the patient can be treated without surgery. However, antibiotics are often administered prior to surgical exploration in patients who develop an indication for surgery. Observation observation (beginning in the intensive care unit) is often indicated for hemodynamically stable patients with solid organ injury. Many of them are healthy by itself again. Patients who can be seen in the CT amounts of free liquid, but no specific organ injury could be identified, are also observed, provided they have no signs of peritoneal dialysis. However, free fluid is no evidence of solid organ injury also the most frequent radiological findings in hollow organ injuries, although this finding has a low specificity. Because observation in Hohlorganperforationen is not suitable, since many patients develop sepsis due to peritonitis, the doctor should start a lower threshold for surgical exploration in patients with isolated free fluid and deteriorated condition after a certain period of observation. During observation the patients several times a day tested (preferably by the same examiner). For this, a blood count is made usually every 4-6 h. It is further checked regularly for signs of bleeding and peritonitis. A current circulation is nahegelgt by a worsening of the hemodynamic status of a continuous need for transfusion (eg., Greater than 2-4 units over a period of 12 h), a significant decrease of hematocrit (for. Example, from> 10 to 12% ) the importance attached to the need for transfusion and the change of the hematocrit value depends on the injured organ from, and (of other associated injuries such. as injuries, which also provide blood loss), but also on the physical condition of the patient. In patients with suspected significant bleeding angiography with embolization or immediate laparotomy should be considered. Peritonitis requires further investigation by DPL, CT or, in some cases, by exploratory laparotomy. Patients who are stable, are normally moved to 12-48 h to a regular station, depending on the severity of abdominal and other injuries. Activation and nutrition are performed as the patient tolerates it. Normally, patients can be discharged home after 2-3 days. However, you are encouraged to limit their activity for a period of 6-8 weeks at a minimum. It is not clear which require asymptomatic patients an imaging examination before resuming normal everyday life, especially when heavy lifting, contact sports or re abdominal trauma are likely. Patients with high grade injuries (ie Grade 4 and 5) have the highest risk of developing complications and should most likely an imaging erhalten.Laparotomie A laparotomy is either because of injury or because of the clinical status performed (z. B. hemodynamic instability ), or because of a subsequent clinical decompensation. In most patients, a single intervention is sufficient, in which stopped the bleeding and injuries to be repaired. However, patients with extensive intra-abdominal injuries, undergoing a lengthy initial surgery, often worse off, especially if they also have other serious injuries or who have suffered a prolonged shock. The more extensive and lengthy the first operation, the more likely patients develop very lethal combination of acidosis, coagulopathy and hypothermia followed by multiple organ failure. In such cases, the mortality can be reduced that the surgeon first performs a shorter engagement (a so-called mitigating operation), be controlled in the circulation and enteric spillage (eg., By packaging, ligature, setting of shunts sewn or stapled intestine) and the belly is temporarily closed. A temporary closure can be manufactured using a closed suction vacuum system from towels, drainage and large air-permeable dressings or by using a vacuum dressing commercially available for the belly. The patients are then stabilized in the intensive care unit and taken to the dressing removal and final repair to the operating room as soon as her condition has returned to normal (particularly the pH and the temperature): This is usually within 24 hours of the case -or earlier when her condition, despite a recovery clinically deteriorated. Since patients are subjected to a mitigating intervention are severely injured, the mortality is still high and subsequent intra-abdominal complications are häufig.Angiographische embolization Ongoing bleeding may sometimes without surgery by embolization of the blood-ended vessel with a percutaneous angiographic procedure (angiographic embolization) being stopped. Eine Hämostase wird durch Injizieren einer thrombogenen Substanz (z. B. pulverförmige Gelatine) oder durch metallische Spulen in das blutende Gefäß erreicht. Obwohl es darüber keinen Konsens gibt, gehören zu den allgemein akzeptierten Indikationen für eine angiographische Embolisation die Folgenden: Pseudoaneurysma Arteriovenöse Fisteln Verletzung eines soliden Organs (insbesondere der Leber) oder eine Beckenfraktur mit Blutungen, die stark genug sind, um eine Reanimation oder Transfusion zu erfordern Die angiographische Embolisation wird nicht für instabile Patienten empfohlen, weil die Radiologieabteilung keine optimale Umgebung für die Bereitstellung von Intensivpflege ist. Zusätzlich sollten verlängerte Versuche einer Embolisation bei Patienten, deren Blutungen kontinuierliche Transfusion erfordert, fallengelassen werden. Ein operativer Eingriff ist hier eher am Platz. Doch mit zunehmender Verfügbarkeit von Hybrid-OPs (OP mit angiographischen Interventi

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