Common Surgical Diseases: An Algorithmic Approach to Problem Solving

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Again, IV fluids and blood should be warmed. Adjuncts: During the primary survey, blood pressure, EKG, and pulse oximeter monitors should be placed. Supplemental oxygen should be administered. If clinically indicated, a nasogastric tube and Foley catheter are inserted. Basic imaging, including chest, pelvis, and lateral cervical spine radiographs, as well as FAST scan can also be obtained at this point.

A complete neurologic exam is performed. Do not let diagnostic studies delay transfer to definitive care. Airway Speaking? NO Protecting airway? Chest tube Flail chest? Chest tube Open PTX? Tension PTX? Response D. Petrey A. Initial Resuscitation: A systematic approach to the trauma patient with a suspected head injury is essential in order to provide an expedient diagnosis and treatment. The head is one of the most commonly injured structures of the body; trauma can cause a constellation of symptoms including a decrease in mental status or loss of consciousness.

Other etiologies of loss of consciousness must also be considered including shock, seizures, metabolic disturbances, and intoxication. Patients who are spontaneously breathing may be observed. However, patients who present with altered mental status and inability to protect their airway need to be intubated, either orally or nasally. Head-injured patients have a high likelihood of cervical spine injury; therefore, cervical spine stabilization should be maintained at all times, even when intubating.

Breathing should be assessed next with auscultation of the chest cavity for breath sounds. Definitive treatment is needed for pneumoor hemothorax or other injuries affecting ventilation. Two large-bore peripheral IVs should be placed and resuscitation started with crystalloid fluid and blood, if needed for severe hypotension. Hypotension and hypoxemia can be devastating for the patient with a head injury and may actually cause secondary insult to the brain.

All efforts should be made to maintain blood pressure and oxygenation for adequate cerebral perfusion. Assessing Neurological Status: Primary survey of the headinjured patient also entails a neurological examination. Patients are evaluated in three categories using the best response in eye opening, motor, and verbal. Scores range between 3 and 15, with 3 being no response to any stimulus and is the lowest score. Any patient suspected of having increased intracranial pressure ICP or a GCS score between 3 and 8 should be treated with intubation and mild hyperventilation to maintain pCO2 between 30 and 35 mm Hg.

Hyperventilation should only be used for short periods of time, as this has been shown to increase areas of ischemia in the injured areas of the brain. A more complete head examination should be included in the secondary survey of the injured patient. Signs of head injury include seizure activity, hemiparesis, and decerebrate or decorticate posturing. Raccoon eyes or periorbital ecchymosis, postauricular ecchymosis bruising behind the ears , hemotympanum, signs of CSF leak otorrhea or rhinorrhea , or injury to cranial nerves may be signs of a basilar skull fracture.

The cranium should be checked for skull fractures or depressions. Large lacerations should be gently probed to check for open fractures. Differential Diagnosis: Other causes of depressed mental status should be quickly considered. Glucose levels should be checked and treated. The presence of alcohol and drugs should be checked with blood and urine alcohol and drug screens. Administration of naloxone or flumazenil may be considered for emergent reversal. Radiographic Assessment: Once the initial stabilization and evaluation are complete, the patient is taken as quickly as possible for a noncontrast CT scan of the brain.

Abnormalities sought for include mass lesions e. Surgical Emergencies: Care should be rendered at a facility where neurosurgical care is available around the clock. If this is not available at the initial facility, transfer of the patient is essential. Acute subdural hematomas are life-threatening extra-axial blood collections caused by tearing of the bridging veins found between the cerebral cortex and the overlying dura.

Subdural hematomas are often associated with more severe 33 34 L. Petrey Table 8. Glasgow Coma Scale. Points Eye opening Spontaneous To voice To stimulation None 4 3 2 1 Motor response To command Localizes Withdraws Abnormal flexion Extension None 6 5 4 3 2 1 Verbal response Oriented Confused but comprehensible Inappropriate or incoherent Incomprehensible no words None 5 4 3 2 1 generalized brain injuries and cerebral contusions. They appear as a concave rim of localized blood around the brain on CT scans. Subdural hematomas greater than 1 cm are often associated with decreased mental status and midline shift.

Treatment is with craniotomy and decompression. Epidural hematomas are usually caused by blunt trauma to the head, producing tears in the meningeal vessels, typically the middle meningeal artery in the temporal area. They may also be associated with skull fractures, which traverse the superior sagittal or transverse sinuses.

The history is that of a patient who has a transient loss of consciousness after a head injury, followed by a lucid phase and then neurological deterioration. Epidural hematomas have a convex shape on CT. Most epidural hematomas require emergent evacuation in the operating room. Depressed skull fractures require surgical elevation when the depth of the depression meets or exceeds the thickness of the adjacent skull or is greater than 8—10 mm. Also, they require elevation when a cerebrospinal fluid leak is suspected or when a neurological deficit is related to pressure or injury of the underlying brain by the fracture.

Open depressed fractures should be treated promptly to minimize the risk of infection and antibiotics should be administered. Penetrating injuries and gunshot wounds to the cranium usually have a very poor prognosis and are often accompanied by intra- or extra-axial cerebral hematomas, contusions, and bone fragments or debris in the tracks. Treatment is very controversial.

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Nonsurgical: Emergencies are best treated by controlling the ICP. Patients with a GCS score of less than 8 should be intubated and treated with mild hyperventilation. Hyperventilation for long periods has fallen out of favor and is recommended only for brief periods Head Trauma A. Differential Diagnosis hypoglycemia, alcohol intoxication, drugs D. Radiographic Assessment CT head E. Surgical Emergencies 1. Non-surgical Emergencies 1. Nagy A. Need for an Airway: It is important to assess the airway of every trauma patient encountered. Indications for further airway intervention include apnea, respiratory distress, airway obstruction, and inability to protect the airway.

A patient with a depressed level of consciousness due to head injury or shock will be unable to protect the airway and may have airway obstruction due to the tongue falling posteriorly into the oropharynx. Initial Maneuvers: When it is decided that a patient needs an airway intervention, the oropharynx should be cleared of secretions and foreign bodies.

A Yankauer suction is used to remove secretions such as blood, saliva, and vomitus. Two quick methods for opening the airway are the chin lift and the jaw thrust. The jaw thrust is performed by pushing both angles of the mandible anteriorly. Both can be done without any flexion or extension of the cervical spine.

Any patient who has sustained trauma above the clavicles should be considered at risk for a cervical spine injury and care should be taken not to manipulate the neck. This will further open the airway. The airway may be maintained in an open position by the use of an oral airway or a nasal airway. The nasal airway is preferred in awake patients because the oral airway may induce a gagging sensation.


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The nasal airway is contraindicated in the presence of a coagulopathy, midface trauma, or a suspected basal skull fracture. Definitive Airway: Most patients require a more definitive airway than that provided by the oral or nasal airway. These patients should have an endotracheal intubation performed. It is important that all equipment be checked prior to embarking upon this. The physician should don gloves, mask, and eye shield and ensure that the laryngoscope light, suction, and endotracheal cuff are in working order.

The ambu bag should be connected to an appropriate size face mask and an oxygen source. Assistants are useful for cervical spine immobilization or cricoid pressure. If rapid sequence intubation is being performed, intravenous access should be present. An appropriately sized laryngoscope blade should be used. The MacIntosh curved blade is useful for patients with large tongues but requires more skill to place into the vallecula. The Miller straight blade is used to lift the epiglottis directly.

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The laryngoscope is held in the left hand and advanced into the oropharynx. Once in place, the laryngoscope is pulled anteroinferiorly not levered onto the upper teeth and the vocal cords are visualized. The endotracheal tube is advanced through the cords under direct visualization. Nasotracheal intubation may be used in the awake patient; however, it is discouraged because of the relatively high incidence of sinusitis and otitis resulting from prolonged intubation.

Rapid sequence induction is a valuable adjunct to oral endotracheal intubation. This requires intravenous access. There are several different drugs which may be given. It is important to maintain cricoid pressure continuously beginning with the administration of drugs until the tube position has been confirmed by auscultation. Occasionally, it will be difficult to obtain an airway using this standard technique. This is done by inserting an gauge needle through the 37 38 cricothyroid membrane into the airway. A guide-wire from a central line insertion kit is then advanced through the needle retrograde into the oropharynx.

Using a laryngoscope to visualize the posterior pharynx, the wire is grasped with a Magill forceps and retrieved through the mouth. The endotracheal tube is then threaded onto the wire and advanced into the trachea. Once the tube is through the vocal cords, the wire is removed and tube position is confirmed by auscultation. Fiberoptic intubation may be useful in certain circumstances.

This requires a spontaneously breathing patient and a physician who is skilled in using the flexible bronchoscope. This technique is not indicated for emergent airways because time is of the essence. Adequate local anesthesia of the nasopharynx and oropharynx are essential. The endotracheal tube is placed over the bronchoscope before insertion, when the vocal cords are visualized, the tube is then advanced directly into the airway. Many trauma patients are not candidates for this technique because excess blood and secretions may hinder visualization. In addition, patients with penetrating neck trauma may gag on the bronchoscope, leading to a Valsalva, which may result in bleeding from a carotid or jugular injury.

These patients are better candidates for rapid sequence induction technique with a surgeon prepared to perform a cricothyroidotomy if intubation is unsuccessful. Surgical Airway: If the patient is desaturating and an immediate airway is necessary, a surgical cricothyroidotomy should be performed if attempts at oral intubation have been unsuccessful.

A 2—3-cm transverse incision should be made directly over the cricothyroid membrane. This incision should be carried through the skin, subcutaneous tissue, and membrane. Once the airway is entered, a tracheal hook is placed to stabilize the thyroid cartilage. The membrane may be gently dilated with a tracheal dilator or hemostat. The K. Nagy tracheostomy tube is then placed through the cricothyroid membrane into the trachea. This tube should be no larger than a 6 Shiley or 7. Once inserted, placement is confirmed by auscultation and the tube is secured to the patient.

A transverse incision is best as it facilitates rapid access through the cricothyroid membrane. If laryngeal pathology such as a fracture is suspected, the surgeon may choose a longitudinal midline incision instead. This incision may more easily be extended inferiorly if an emergent tracheostomy is necessary due to distorted laryngeal anatomy. Pediatric Intubations: Pediatric intubations require special consideration. Very young children should be pretreated with atropine prior to manipulation of their airway. Children younger than 8 years should have an uncuffed tube placed.

Surgical cricothyroidotomies are contraindicated in children younger than 8 years. If endotracheal intubation cannot be performed, a needle cricothyroidotomy may be necessary. Once air is aspirated, the metal needle is removed and the hub of the catheter is connected to an ambu bag or ventilator tubing.

This is performed by using the adapter from a 3. Needle cricothyroidotomy will provide adequate oxygenation and ventilation for a few hours until a formal tracheostomy can be performed. This catheter is too small to adequately ventilate an adult patient. Unsuccessful or patient desaturating C.

Pediatric Intubation Uncuffed tube for Children 10 Penetrating Neck Trauma Mark Falimirski The neck has many vital structures packed into a small amount of space vulnerable to penetrating trauma. Injuries to the airway and arteries that course this region are the primary cause of immediate morbidity and mortality. Penetrating injury may be caused by projectile or blade with each assuming different subtleties in management. Penetrating injury caused by projectiles is associated with a higher incidence of significant injury, yet a stab wound tract commonly is more difficult to delineate, often underestimating the potential for and significance of injury.

Absolute indications, regardless of mechanism, such as hemorrhage, expanding hematoma, neurologic deficit, airway compromise, or impaled object necessitate emergent surgical management. Other symptoms such as subcutaneous emphysema, hemoptysis, stridor, odynophagia, or dysphagia also often necessitate urgent surgical exploration. The neck is divided into three zones by horizontal planes. Two different classifications are described based on different borders.

Monson et al. Here, Zone I is described as below the medial head of the clavicles, Zone II between the medial head of the clavicles and the angle of the mandible, and Zone III above the angle of the mandible. This classification was proposed to better identify areas of the neck that warrant further diagnostic studies namely angiography prior to operative management in preparation of appropriate and possibly complicated exposure.

Later, a second definition was introduced changing the borders of Zone I and II to the cricoid cartilage. It is important when reviewing this literature to make this distinction for comparison of outcomes. Zone I injuries often necessitate median sternotomy or clavicle resection while Zone III injuries may require mandibular disarticulation; hence the need for further diagnostic modalities in preparation for operative management. The first priority in trauma management is the institution of the American College of Surgeons Advanced Trauma Life Support guidelines.

The airway is insured of patency and protection, breath sounds are confirmed bilaterally and circulation is identified with peripheral pulses. If the patient requires an artificial airway, a surgical tray should be available because tracheal injury or neck hematoma may often render an endotracheal intubation unsuccessful. Many advocate bronchoscopic aid in intubation so as not to create a false passage with direct laryngoscopy. Regardless of intubation, a chest radiograph CXR is promptly obtained to identify potential thoracic pathology i.

Once the primary survey is complete, a better evaluation of the neck and all other possible injuries can ensue. Physical examination of the neck first takes into account the previously listed absolute indications for immediate operative intervention regardless of zone of injury. If immediate operative intervention is required, the patient should be prepped and draped for a possible median sternotomy or mandible disarticulation and neck exploration performed.

An incision is made along the anterior border of the sternocleidomastoid muscle and the course of the wound explored. If absolute indications for exploration are not present, a more thorough examination of the neck is performed after all immediate other life-threatening injuries are addressed.

Local wound exploration is next performed to identify depth of penetration. If the platysma is deemed intact or not penetrated, no further work up is necessary. When the platysma is deemed violated, the next priority is to identify which zones are involved. GSWs are managed only slightly different here. An AP neck film is obtained for GSWs with a presumed retained projectile to identify potential multiple zones of involvement.

A CXR will identify any projectile that exited the neck into the thorax. Involvement of Zone I, III, or multiple zones require arteriography to evaluate for a potential vascular injury and esophagography for a potential esophageal injury. If esophagography is equivocal, then rigid esophagoscopy is indicated.

Again, this is done for these zones of injury for 1 preparedness of an extensive surgical approach outside of a standard neck exploration and 2 to possibly obviate surgical management. Also, many Zone III injuries are inaccessible via surgery and transcatheter embolization may be required for definitive management. Bronchoscopy and laryngoscopy is performed in stable patients with upper airway trauma evidenced by dyspnea, hemoptysis, subcutaneous emphysema, or air bubbling through the wound.

Multiple zones of injury secondary to stab wounds SW are more difficult to appreciate because depth and angle of penetration are not easily determined. Therefore, Zones I and III injuries are managed as previously described above without the need for plain films of the neck. A CXR may also aid in identifying thoracic involvement. A distinction between a stab and slash wound will also dictate different management tracts. A true slash wound essentially exposes the base of the injury obviating the need for further diagnostic studies and dictating surgical management as needed including a complex closure.

The greatest controversy in penetrating neck trauma is the management of isolated Zone II injuries. Proponents of mandatory neck exploration however believe that any delay in operative intervention leads to higher morbidity and mortality. It is also associated with a low morbidity and most patients can be discharged within 24 h after operative management. Most recent reviews do not show a greater benefit with either M. Falimirski procedure. The decision to perform selective management or mandatory exploration should be made with each individual institution based on afforded resources.

One caveat should be considered.

Common Surgical Diseases An Algorithmic Approach to Problem Solving

Many proponents of selective management cite a significant strain on resources to perform mandatory exploration. This strain can be no greater than that performed coordinating and completing the multiple diagnostic studies with selective management. The definitive management of carotid artery injuries is somewhat controversial.

Multiple factors have been considered to direct surgical repair including ischemic time, neurological impairment, presence of carotid flow, etc. Many recent studies have shown improved success of these injuries with surgical repair despite neurologic exam. Earlier contraindications to repair and reestablishment of flow were based on the possibility of converting an ischemic infarct to a hemorrhagic one.

Kuehne from the University of Southern California prospectively studied revascularization in internal carotid artery injuries and showed improved results despite neurologic impairment. However, a dense neurologic deficit with carotid artery occlusion and a hemispheric infarct still proposes a poor prognosis despite surgical management. Venous injuries are ligated with impunity. Esophageal injuries should be primarily repaired and drained with a soft flexible drain.

Tracheal injuries are also primarily repaired. Tracheostomy placement is based on level of injury but is not commonly required. Recently, publications have pointed to physical examination as means of identifying diagnostic and therapeutic management of vascular injuries. Although the evidence is broad and convincing, many more studies are needed to confirm these preliminary results.

A key principle in the management of these injuries is that outcomes improve with shorter transport time. Certain interventions may be performed in the field or at nontrauma centers to prevent imminent death, but rapid evacuation to a trauma center should not be delayed. Survivors are taken to the operating room for definitive surgical repair of injuries.

It should be noted that there is considerable surgical controversy surrounding the amount and type of resuscitative fluids used, as well as the indications for pericardioscentesis and emergency thoracotomy. Airway assessment: If there is any question regarding ability to maintain an airway, prompt intubation and positive pressure ventilation should be performed. Secondary survey: The stable patient can be more carefully assessed during a secondary survey. Wound location s is noted. All patients suspected of having hemo- or pneumothoraces are evaluated with an arterial blood gas and baseline chest x-ray.

If positive for injury, a tube thoracostomy is placed. Because of the small but real possibility of slow-onset pneumothorax, patients with a negative baseline chest x-ray should have a repeat x-ray at 6 h. If positive for injury at that time, a tube thoracostomy is placed. Patients must be carefully monitored for changes in the ABCs during the observation period.

Injuries to specific areas are as follows: B. This can rapidly lead to a pneumothorax. This requires an immediate, occlusive bandage. The unstable patient with a penetrating chest injury should undergo ipsilateral or bilateral needle thoracostomies in the field to alleviate tension pneumothorax.

Definitive management of this injury is tube thoracostomy; one does not need to perform a chest x-ray before placing a chest tube for the unstable patient. Tube thoracostomy is also indicated for hemothorax. Thoracotomy is also necessary for persistent large air leaks from the thoracostomy tube. If, at any time, airway or breathing becomes compromised, prompt intubation and positive pressure ventilation should be performed. Assess circulation: Large-bore peripheral IVs should be inserted for every patient and resuscitative fluids started.

Causes of hemodynamic compromise include tension- and hemopneumothorax, external blood loss, and pericardial tamponade. A pericardioscentesis during transport or at a nontrauma center may alleviate pericardial tamponade but should not delay transport to a trauma center. The patient in extremis E. Eighty percent of penetrating chest wounds which injure the heart occur in this space. If a stable patient has an injury in this box, an echocardiogram is done to assess for the presence of pericardial fluid. The echocardiography may be done on its own or as part of the focused abdominal sonography for trauma FAST exam.

If there is fluid, the patient is taken to the operating room for a subxiphoid pericardial window. Blood found in the pericardium indicates a possible cardiac injury and the need for sternotomy and exploration. This box is bounded by the scapulae. Stable patients undergo tests to rule out injury to these structures. Angiography is the gold standard to rule out aortic injury, but transesophageal echo has been used successfully at several centers to view the descending aorta.

Occasionally, mediastinal air 45 46 indicating esophageal injury is seen on plain chest x-ray; however, this is not very sensitive. Aortic and esophageal injuries must be promptly repaired surgically. Rarely, a stable patient with a persistent chest tube air leak, crepitus, or changes in phonation will be found to have an airway injury on bronchoscopy. Management of these injuries is individualized. Thoracoabdominal injuries: Thoracoabdominal injuries are to be suspected with wounds that occur from the M. Crandall nipples to the costal margins anteriorly and the scapular tips to the costal margins posteriorly.

The concern with these injuries is that the diaphragm may have been traversed and the abdominal cavity entered. Many trauma surgeons believe that all diaphragm injuries should be repaired because of the risk of herniation of abdominal contents into the chest. To assess this, a diagnostic peritoneal lavage is performed. A red blood cell count over 10, indicates abdominal penetration, hence diaphragmatic penetration and injury. These patients are taken to the operating room for exploratory laparotomy and prophylactic ipsilateral thoracostomy tube.

Waltenberger A. Primary Surgery.


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As with any trauma, the management of penetrating abdominal trauma begins with the primary survey and the ABCs Airway, Breathing, and Circulation. If the patient remains unstable after 2 L of crystalloid, blood should be administered. If cross-matched blood is not readily available, type O blood Rh negative for female patients of childbearing age or typespecific blood may be safely transfused. A quick assessment of any immediately life-threatening injuries should be undertaken and the patient should be disrobed.

Eviscerated abdominal contents should be covered with sterile, saline moistened gauze, but not manipulated further. Retained implements bladed weapons should be left in position, as premature removal may result in loss of vascular tamponade, massive, uncontrollable hemorrhage, and death. Baseline lab studies include a complete blood count, electrolytes, coagulation studies, pregnancy test, urinalysis, toxicology screen, and a blood sample for type and cross-matching.

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A nasogastric tube NGT and Foley catheter should be inserted. A thorough exam is performed of all orifices, identifying all the injuries and classifying them by mechanism bullet, stab wound, shotgun, etc. Immediate indications for surgery include shock, transperitoneal path of bullet, evisceration, peritonitis, free air on x-ray, retained stabbing implement, or gross blood per NGT or rectum. The focused assessment for the sonographic examination of the trauma patient FAST is a rapid diagnostic test used during the secondary survey.

Its limitations are that it has a long learning curve and misses hollow viscus injuries. All injuries from penetrating trauma should be evaluated with plain films using radiodense markers on the wound sites. This allows the physician to determine potential missile trajectories and possible transperitoneal path. Once a bullet is seen, a lateral film is used to define its location. In addition to mechanism, wounds are characterized by location. The locations of importance are thoracoabdominal, anterior abdomen, back and flank, and pelvis.

The diaphragm at the end of full expiration may rise as high as the fourth intercostal space anteriorly and the tips of the scapula posteriorly. The anterior abdomen is from the costal margin to the inguinal ligament, anterior to the mid-axillary line. The back and flank region is bordered by the scapulae superiorly and the iliac crest inferiorly, posterior to the mid-axillary line. Stab wounds most commonly occur in the upper anterior quadrants. Some institutions advocate local wound exploration LWE for anterior abdominal stab wounds, while others immediately proceed to diagnostic peritoneal lavage DPL.

While blunt probing of wounds is unreliable and potentially dangerous, LWE can be carried out safely under aseptic conditions and local anesthesia. This procedure entails surgically extending the wound in order to better visualize the injury tract. An intact posterior fascia constitutes a negative LWE, and management consists of gentle wound irrigation, closure of the extended portions of the wound, and discharge. In cases where clear peritoneal violation or posterior fascial disruption is observed positive LWE , and in cases where the entire wound tract cannot be adequately visualized equivocal LWE , the exploration 49 50 is considered positive, and further testing to identify possible visceral injury is indicated.

DPL can be used to quickly determine whether a patient with a penetrating abdominal injury has either intra-peritoneal hemorrhage or peritonitis. Aspiration of gross blood, bile, or bowel contents is an indication for laparotomy. In an adult 1 L of. CT scans can easily miss small bowel and diaphragm injuries. Contraindications to DPL include pregnancy, obesity, and prior abdominal surgeries. The role of laparoscopy in trauma is still not clear; however, it may be a useful tool for abdominal stab wounds.

Visualization of the adjacent peritoneum while probing the wound may confirm or refute peritoneal penetration. It is sensitive for identifying small liver, splenic, or diaphragmatic injuries. Small splenic and liver injuries can often be managed without laparotomy and an uncomplicated diaphragm injury may be repaired laparoscopically. Gunshot wounds. The treatment of gunshot wounds GSWs is different than that of stab wounds. If penetration of the peritoneal cavity can be demonstrated based on radiographs, physical exam, or bullet trajectory , then operative intervention is indicated, even if the patient is stable.

They should also be worked up for pneumothorax. Triple contrast CT is the first test of choice in patients with back and flank wounds. This allows one to evaluate the retroperitoneum and hopefully identify the tract of the bullet. If the tract cannot be clearly identified and there is no indication for laparotomy, a DPL should be performed. Penetrating pelvic wounds may result in injury requiring laparotomy. The outlet tracts must all be evaluated depending on possible trajectory.

If the bladder is at risk, a cystogram should be performed. Proctoscopy is performed to rule out rectal injury. Females should have a vaginal speculum exam. Once the decision is made to take the patient to the operating room, IV antibiotics and tetanus toxoid should be given. Control of hemorrhage is the first priority. The abdomen should be rapidly inspected in a systematic manner, taking care to survey and pack all quadrants; the mesentery, omentum, diaphragm, and retroperitoneum should be inspected. Second priority is controlling contamination.

Gross contamination from hollow viscus injuries can be temporarily controlled with bowel clamps or a quick suture. Intestinal repair should be undertaken after hemorrhage has been controlled. Injury to the retroperitoneum is suspected when there is bile staining, a retroperitoneal hematoma, or crepitation in the tissues. In these situations, structures which may sustain retroperitoneal injury right colon, left colon, splenic and hepatic flexures, and the duodenal sweep should be mobilized for better identification and repair of injury.

Once the necessary repairs have been completed, the entire abdomen should be copiously irrigated with warm saline. Stab Wounds B. Secondary Survey, Resuscitation labs A. Injuries can occur with direct blows, by shear forces, with rupture of a hollow viscous from increased intra-abdominal pressure, or from crushing between the abdominal wall and the vertebral column.

Once this is underway, the evaluation of a patient with blunt abdominal trauma begins. Secondary survey: A secondary survey is performed, examining the patient from head to toe. The focused abdominal sonogram for trauma FAST exam is gaining popularity around the country. Many studies have validated its use as a screening tool for hemoperitoneum and fluid within the pericardial sac.

Trained trauma staff can rapidly perform this specific ultrasound exam. FAST sequentially checks for blood in the pericardial sac, right upper quadrant, left upper quadrant, and the pelvis. A full urinary bladder is required. For cardiac imaging, the transducer is positioned in the subxiphoid region. To inspect for blood between the liver and right kidney, the probe is placed in the right midaxillary line between the 11th and 12th ribs. On the left side, the probe is placed between the 10th and 11th ribs in the left posterior axillary line.

For imaging the pelvis, the probe is positioned transversely 4 cm above the bladder. Stable patients with blunt trauma who are conscious, not intoxicated, and have no distracting injuries head, extremity may be expected to provide a reliable abdominal exam. If these patients do not have abdominal pain or tenderness to palpation, observation is sufficient. Patients with blunt abdomi- nal trauma who require surgery for other injuries during the period of observation, and patients whose exam changes i. CT is generally preferable for patients who are stable and can be transported away from the resuscitation area.

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The hemodynamically stable patient with an unreliable exam, due to intoxication or head injury, should undergo CT scan. DPL can be used as well. Unstable patients and patients being hurried to the operating room for other injuries e. Transport to the radiology suite may not be safe, hence the need to use an alternative to CT scanning to assess for intra-abdominal injuries. These patients should undergo DPL, as it can be performed quickly and does not require transport of the patient away from the trauma resuscitation suite. If the FAST exam is available, it can be used to determine whether or not hemoperitoneum, cardiac tamponade, etc.

Very rarely, a patient will present after blunt abdominal trauma with signs of an obviously injured abdomen e. These patients should not undergo diagnostic testing, as they require immediate laparotomy. All other patients with a work up indicating high likelihood of life-threatening visceral injury should undergo exploratory laparotomy.

Spleen: The spleen is the most commonly injured organ in blunt abdominal trauma. Seventy percent of injuries to the spleen may be managed nonoperatively with bed rest and 48 h of careful monitoring and serial hemoglobin checks. Patients who become unstable during the period of observation or have evidence of ongoing hemorrhage should undergo abdominal exploration.

Splenic salvage splenorrhaphy with hemostatic agents, splenic wrapping, or hemostatic sutures and partial splenectomy may be successful in a subset of stable patients. Crandall Table Findings suggestive of visceral injury. Hepatic injury grading. Scoring system for splenic injuries. Neonatal Intensive Care Units. Live Birth. Infant Mortality. Birth Weight. Premature Infants. Gestational Age. Survival Rate. If an item is faulty, wrongly described, or different from the sample shown then we will meet our legal obligation which may include refunding the purchase price and delivery charges.

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