Diaphragmatic
injury
Diaphragmatic
injury is more common following
penetrating trauma than blunt trauma. The
most common injury is 5 to 10cm in
length, involving the poster lateral
left hemi diaphragm The right diaphragm
is protected by the liver hence injury
is less common. Evaluation of Chest
X-ray may show, elevation of the
diaphragm, poor identification
(irregular or obscure) due to overlying
fluid or soft tissue masses, mass-like
density above the diaphragm, air or
contrast-containing stomach or bowel
above the diaphragm, contra lateral
mediastinal shift and widening of the
cardiac silhouette if the peritoneal
contents herniat into the pericardial
sac. Ultra sonography may identify the
herniation of the abdominal contents.
Diaphragmatic laceration should be
repaired with interrupted,
non-absorbable, mattress sutures. Large
diaphragmatic defects require the use of
a prosthetic mesh.
Stomach
Gastric
rupture secondary to blunt trauma is
uncommon. Most full thickness gastric
injury is due to penetrating trauma.
Chest X-ray may show gas under the
diaphragm. Ultra sonography and CT scan
of the abdomen may be required to
identify the rupture. Stomach wounds can
usually be debrided and safely closed
primarily.
Duodenum
About
75% of duodenal injuries result from
penetrating trauma, and 25% from blunt
injuries.. Duodenal rupture is
classically encountered in the
intoxicated, unrestrained drive involved
in a frontal-impact motor vehicular
accident or by a blow to the abdomen by
bicycle handlebars. A bloody nasogastric
aspirate or retroperitoneal air should
raise one’s suspicion. Water-soluble
contrast studies of duodenal c loop or
double contrast CT is indicated for the
high-risk patient. Most simple duodenal
wounds can be closed primarily. More
extensive injuries may be managed by
using a variety of techniques like
closure of the injury with a tube
duodenostomy, decompression through a
separate incision proximal to the
injury, omental or serosal patch,
gastroenterostomy, and duodenal
diverticulization
Pancreas
Pancreatic
injury most often results from a direct
epigastric blow compressing the organ
against the vertebral column..
A normal amylase level does not
exclude major pancreatic trauma;
conversely, the amylase level may be
elevated from nonpancreatic sources.
Even double-contrast CT may not
identify significant pancreatic trauma
in the immediate post injury period.
If pancreatic trauma is found, it is
important to assess the integrity of the
pancreatic duct. In stable patients,
severe injuries of the body and tail as
well as ductal injuries are managed by
distal pancreatectomy.
Injuries of the head of the pancreas
that do not involve the duct, adjacent
vessels, ducts or organs are managed by
appropriate surgical drainage.
Pancreaticoduodenectomy is indicated
when there is involvement of ampulla,
bile duct or proximal pancreatic duct.
Small
bowel
Blunt
injury to the intestines generally
results from sudden deceleration with
subsequent tearing near a fixed point of
attachment. Diagnosis may be difficult,
especially since minimal bleeding may
result from torn intestinal organs. CT
is often not diagnostic. Simple injuries
are closed primarily. Multiple
perforations, mesenteric lacerations or
a segment of non-viable bowel would
require resection and anastomosis.
Colon
Common
in deceleration or compression injury.
Primary repair or resection and
anastomosis is the procedure of choice.
However defunctioning colostomy is safer
in the following situation, unstable patient, gross
fecal contamination, delay to surgery of
more than 8 hours, more than two intra-abdominal organ systems injured and
high-velocity missile wound or Bomb
blast to abdomen
Rectum
Rectal
injury is more common with penetrating
injuries. Generally rectal injury above
the peritoneal reflection can be primary
closed or resection and anastomosis done. Rectal injury below the peritoneal reflection would require
defunctioning colostomy, drainage of the
presacral space and irrigation of the distal segment of the bowel
Spleen
Spleen
in the most common solid organ injured
in blunt abdominal trauma.
If the damage is minimal salvage
procedure can be done i.e. Partial
splenctomy or mesh splenorrhaphy. When
parenchymal injury is more severe and
haemorrhage is continuing and if there
is hameodynamic instability or
associated major injury, splenectomy is
the favored treatment
Liver
Following
penetrating trauma, the liver is the
organ most commonly injured. Most trauma
units prefer non-operative management of
liver injury. Studies have shown there
is significant lower transfusion
requirement in non-operative group when
compared to operative group. Unstable
patient require emergency laparotomy and
one of the following operative
management may be required, Gauze
packing, Omental packing, Resectional
debridment, Mass liver suture Hepatic
artery ligation
or Total hepatic isolation
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