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    Trauma Tumpul Abdomen: Stase Bedah Digestif Januari 2019

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    ArifHidayat
    1. The document discusses the anatomy of the abdomen, mechanisms of injury in blunt abdominal trauma including compression, shearing, and injuries to solid organs like the liver and spleen. 2. Clinical manifestations of abdominal trauma are discussed, including internal bleeding presenting as shock symptoms and signs of blood in the peritoneal cavity. Peritonitis from rupture of hollow viscus is also covered. 3. Diagnostic tools for abdominal trauma evaluation are summarized, including physical exam, FAST, DPL, CT scan, and diagnostic laparoscopy. Each has advantages and limitations for detecting hemorrhage, hollow viscus, and retroperitoneal injuries.

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    Trauma Tumpul Abdomen: Stase Bedah Digestif Januari 2019

    Uploaded by

    ArifHidayat
    66 views49 pages
    1. The document discusses the anatomy of the abdomen, mechanisms of injury in blunt abdominal trauma including compression, shearing, and injuries to solid organs like the liver and spleen. 2. Clinical manifestations of abdominal trauma are discussed, including internal bleeding presenting as shock symptoms and signs of blood in the peritoneal cavity. Peritonitis from rupture of hollow viscus is also covered. 3. Diagnostic tools for abdominal trauma evaluation are summarized, including physical exam, FAST, DPL, CT scan, and diagnostic laparoscopy. Each has advantages and limitations for detecting hemorrhage, hollow viscus, and retroperitoneal injuries.

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    trauma abdomen

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    Trauma Tumpul Abdomen

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    1. The document discusses the anatomy of the abdomen, mechanisms of injury in blunt abdominal trauma including compression, shearing, and injuries to solid organs like the liver and spleen. 2. Clinical manifestations of abdominal trauma are discussed, including internal bleeding presenting as shock symptoms and signs of blood in the peritoneal cavity. Peritonitis from rupture of hollow viscus is also covered. 3. Diagnostic tools for abdominal trauma evaluation are summarized, including physical exam, FAST, DPL, CT scan, and diagnostic laparoscopy. Each has advantages and limitations for detecting hemorrhage, hollow viscus, and retroperitoneal injuries.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    66 views49 pages

    Trauma Tumpul Abdomen: Stase Bedah Digestif Januari 2019

    Uploaded by

    ArifHidayat
    1. The document discusses the anatomy of the abdomen, mechanisms of injury in blunt abdominal trauma including compression, shearing, and injuries to solid organs like the liver and spleen. 2. Clinical manifestations of abdominal trauma are discussed, including internal bleeding presenting as shock symptoms and signs of blood in the peritoneal cavity. Peritonitis from rupture of hollow viscus is also covered. 3. Diagnostic tools for abdominal trauma evaluation are summarized, including physical exam, FAST, DPL, CT scan, and diagnostic laparoscopy. Each has advantages and limitations for detecting hemorrhage, hollow viscus, and retroperitoneal injuries.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 49

    TRAUMA

    TUMPUL
    ABDOMEN
    STASE BEDAH DIGESTIF JANUARI 2019
    ANATOMI ABDOMEN
    Abdomen internal
    Retroperitoneal Zone
    Organ intra abdomen

     Letak
    - Intra peritoneal
    - Retro peritoneal
     Isi organ
    - Organ solid
    - Organ berongga
    MECHANISM OF INJURY
    BLUNT
     COMPRESSION/ CRUSHING
     SHEARING (seat belt improperly worn)
     Fixed organ injury
     ORGAN INJURY:
     Liver
     Spleen
     Hollow viscus
     Retroperitoneal
    TANPA SEATBELTS & TANPA BALON
    Fase 3 AGD

    20
    Indication for Objective Evaluation
    in Blunt Abdominal Trauma.
    Riwayat Penyakit (RPS)
     Mekanisme trauma : prediksi organ dan tingkat kerusakan
     Macam kendaraan
     Tempat/ dimana kecelakaan
     Trauma tumpul
     Posisi penderita/ duduk
     Seat belt, head rest dll
     Pertolongan awal
    History/ RPS

    Blunt
     Speed
     Point of impact
     Intrusion
     Safety devices
     Position
     Ejection
    Assessment: Physical Exam
     Inspection, auscultation,
    percussion, palpation
     Inspection: abrasions,
    contusions, lacerations,
    deformity
     Auscultation: careful exam
    advised by ATLS.
    (Controversial utility in trauma
    setting.)
     Percussion: subtle signs of
    peritonitis; tympany in gastric
    dilatation or free air; dullness
    with hemoperitoneum
     Palpation: elicit superficial,
    deep, or rebound tenderness;
    involuntary muscle guarding
    • DRE (digital rectal examination)
    Manifestasi klinis trauma abdomen

    1. Perdarahan intra-peritoneal
    * gejala dan tanda syok
    * gejala dan tanda
    darah dalam rongga peritoneum
    - nyeri dan nyeri tekan
    - mungkin distensi
    - tanda adanya darah dalam
    rongga abdomen (fisik,DPL,USG)
    Manifestasi klinis trauma abdomen
    2. Peritonitis

    * karena pecahnya organ


    ber-lumen
    * gejala dan tanda
    peritonitis
    PEMERIKSAAN BANTUAN

     FAST
     DPL
     MSCT abdomen
     Laparoskopi diagnostik
     Explorasi luka
    TEHNIK KHUSUS UNTUK MEMBANTU
    DIAGNOSTIK TRAUMA ABDOMEN
    KEUNTUNGAN KERUGIAN

    Pem.Klinik Cepat, noninvasif Meragukan (subjektif)

    DPL Cepat, tidak mahal Invasif, terlalu sensitif,


    spesifiknya terbatas
    FAST Cepat, Noninvasif Tergantung operator

    CT-SCAN Organ specific, informasi Pasien harus stabil,


    retroperitoneal mahal
    LAPAROSKOPI Organ specific Nyeri, perlu narkose
    DIAGNOSTIK umum
    FAST
     Europe  U.S.
     Speed & convenience; noninvasive, costly
     Detection of ‘hemoperitoneum’ at 4 areas,
    sensitivity 90%(75-95%), at least 300 ml
     High degree operator dependency
     Lack of sensitivity for subtle injuries
     Role in intraoperative evaluation,
    eq.thrombosis.
    INDICATION :
    - Hemodinamically unstable w/o obvious indication for laparotomy
    - Requiring prompt transfer to OT for non abdominal cause
    - Screening test for all others requiring abdominal evaluation
    CONTRAINDICATION :
    Obvious need for laparotomy / lack of FAST expertise
    Focused Assisted
    Sonography for Trauma
    (FAST)
    ADVANTAGE DISADVANTAGE  Operator dependence
     Diagnose intra-abdominal  Poor evaluation for hollow
    fluid with a sensitivity of viscous and retroperitoneal
    96% and an accuracy of injury
    99%.
     Cannot detect diaphragm
     Can detect Cardiac
    rupture
    Tamponed
     Can be done in
    Emergency Room (patient
    unstable)
     Easy to use Negative FAST  serial exams
     Repeatable for 6 hours and repeat FAST or
    abdominal CT, depending on
     No radiologic exposure
    Rose JS. Ultrasound in abdominal trauma. Emerg the clinical scenario
    Med Clin N Am. 2004
    FAST RESULT

    FLUID IN HEPATORENAL FLUID IN


    INTERFACE PERICARDIAL SPACE

    FLUID IN PELVIC FLUID IN PERICOLIC FLUID IN SPLENORENAL


    SPACE GUTTER INTERFACE
    DPL
     1965 by Root et al
     Seldinger / open / semi-open
     Very rapid test
     Lack of specificity : blunt, minor injury,
    retroperitoneal & diaphragmatic injury
     Value in patients being taken to OT for
    treatment of extraabdominal injuries
     Accuracy : sensitivity & specificity 95%, false
    negative 4%. Non therapeutic rate 15-27%
    INDICATION = FAST
    CONTRAINDICATIONS : need laparotomy,
    RELATIVE : previous abdominal op,
    pregnancy & pelvic fracture
    DPL: Diagnostic Peritoneal
    Lavage
     Advantage
    High Sensitivity and specificity Disadvantage
    to detect blood  Invasive
     My detect hollow viscous injury  Poor evaluation for
    through detection of its retroperitoneal
    content  Can not detect
    diaphragm injury
     Can not detect the
    source of bleeding
     Unreliable for previous
    operation (due to
    adhesion)
     Relative contra indication
    FAST IS NOW MOST for pregnant
    PREFERABLE
    Diagnostic Peritoneal
    Lavage
     Dekompresi buli dengan kateter urin
     Dekompresi lambung dengan NGT
     Asepsis dan antisepsis
     Injeksi lidocain di midline tepoat dibawah
    umbilicus. Sebaiknya gunakan lidocain dengan
    campuran epinephrin untuk mencegah
    kontaminasi darah pada DPL
     Insisi vertikal pada kulit, sampai dengan fascia
     Jepit tepi fascia dengan clamp dan angkat. Buka
    fascia sampai dengan peritoneum
     Masukkan kateter ke dalam cavum abdomen
     Arahkan kateter ke dalam cavum pelvis
    Sumber : ATLS. 2008
     Hubungkan kateter dengan syringe. Aspirasi
     Jika tidak didapatkan darah. Masukkan 1 liter
    cairan Nacl fisiologis (10 cc/kg untuk anak anak)
     Secara gentle aduk /miring miringkan abdomen
    untuk mencampur darah dengan cairan
     Jika kondisi pasien stabil, biarkan cairan tetap
    berada dalam cavum abdomen selama
    beberapa menit, kemudian hubungkan dengan
    kantung yang ada di lantai. Keluar cairan yang
    adekuat adalah jika keluar > 30 % volume cairan
    infus yang dimasukkan

    Sumber : ATLS 2008


     Setelah cairan keluar, segera kirim ke
    laboratorium untuk pengecatan gram
    penghitungan eritrosit dan leukosit
     Hasil DPL Positif dan membutuhkan
    intervensi bedah adalah jika eritrosit >
    100.000 mm3, leukosit > 500 /mm3, dan
    pengecatan gram positif untuk bakteri
    dan serat makanan.

    Sumber : ATLS 2008


    Sumber : Schwartz’s Principles of Surgery. Tenth edition. 2015
    CT scan
     Late 1970s by Federle & Trunkey.

     High degree of sensitivity & specificity in staging solid organ injuries.


    Accuracy : 92-98%.

     Poor sensitivity for blunt intestinal injury (small amounts of free


    intraperitoneal fluid: 100-200 ml)

     Diagnoses : retroperitoneal hematoma & associated injuries (chest &


    bony pelvis)

     Need time for transportation (hemodynamically stable), expertise of


    experienced radiologic personnel & surgeons, Cost, IV / triple contrast

     False negative 1.6% & false positive 3.2%.

     Late scanning : bowel rupture, pancreas fractures & necrosis

    INDICATIONS : hemodinamically stable

    CONTRAINDICATION : unstable / need laparotomy


    DIAGNOSTIC LAPAROSCOPY (DL)
    IN PENETRATING ABDOMINAL
    WOUND
    RECOMMENDATION

    Diagnostic laparoscopy may be


    considered as a tool to evaluate
    diaphragmatic lacerations and
    peritoneal penetration.
    Laparoscopy
     Specificity is good, but low
    sensitivity for hollow viscous,
    retroperitoneal & blunt trauma
     Advised for penetrating trauma,
    tangential GSW
     More complex : sensitivity, cost,
    time & personnel requirements
     Potential for therapeutic for solid
    organ & diaphragm injuries.
    Kerangka Penanganan
    1. Preparasi
    2. Triase
    3. PS (ABC’s), k/p resusitasi dan px tambahan
    4. SS (History/ RPS & Head to Toe Evaluation) dan px tambahan
    5. Pengawasan pasca resusitasi dan re-evaluasi
    6. Penanganan definitif
    Management Strategy: Avoid
    Second hit
     EGDT
     Treat abdominal compartment syndrome
     Judicious use of fluid resuscitation and blood
    transfusion.
     Pain killer (analgesia)
     Prevent infection
     Prevent surgical complications to minimize the
    requirement of secondary operation.
    Resusitasi

     Problem trauma abdomen yang “life tretening”


    adalah perdarahan
     ! IV-line ganda dan cairan RL hangat
     Menghentikan perdarahan segera, tms
    Laparatomy, merupakan bagian dari resusitasi
    Assessment of Resuscitation

     Vital Signs : BP (≥ 110 mmHg), RR


     Pulse: Rate, Strength
     Skin Color + Temperature
     Capillary Refilling Time
     Urine Output (0,5 ml/KgBW/hr)
     End point for hypotensive resuscitation:
    1. Penetrating trauma – 80-90 mm Hg, / presence of radial
    pulse.
    2. Blunt trauma – 80-90 mm Hg, or presence of radial pulse.
    3. Head injury – 100 mm Hg.
    Algoritma Trauma Tumpul
    Abdomen

    Sumber : Schwartz’s Principles of Surgery. Tenth edition. 2015


    Trauma
    Laparotomy
    Incision
    Perihepatic Packing
    Splenectomy
    Pemeriksaan usus
    Kocher-Cattel Braasch
    Maneuver
    Mattox Maneuver
    Pelvic Packing
    Damage Control
    Abdominal Closure
    TERIMA KASIH

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