Modern surgical medicine Part 2

VIETNAM ACADEMY OF TRADITIONAL MEDICINE AND PHARMACY

Department of Foreign Affairs

PART II: MEDICAL PATHOLOGY TARGET: MEDICAL STUDENTS 3

(Internal circulation)

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TOUCHING THE ABDOMINAL WOUND

I. Objectives:

1. Describe the epidemiological characteristics of abdominal trauma.

2. Describe the clinical symptoms and clinical balance of abdominal trauma

3. Present the principles of treatment.

II. Content:

1. General:

Abdominal trauma is a condition of abdominal injury caused by trauma but there is no communication between the abdominal cavity and the outside environment: the injury can be in the abdominal wall alone, or there can be injury to organs inside the abdominal cavity such as the liver, spleen, intestines...

This is a common surgical emergency. Diagnosis of the presence or absence of intra-abdominal injuries is very important. If not diagnosed and treated promptly, the prognosis is often poor, especially in cases of severe trauma or patients with multiple injuries.

- The frequency of some types of damage is as follows:

+ Spleen: 50% + Small intestine: 12% + Pancreas: 5%

+ Liver: 25% + Large intestine: 8.5% + Duodenum: 3%

+ Kidney: 10% + Stomach: 4% + Bladder: 3%

2. Cause:

Relying on the agent or intensity of trauma to diagnose organ damage is not enough. Severe trauma causes severe damage to the abdominal cavity. However, mild intensity of trauma can also cause damage to the abdominal organs.

2.1. Injuries due to collision:

Such as falling from a height and hitting Ohem against a hard object on the ground (stone wall, log) or being punched or kicked in the Ohem, that is the cause of the collision.

2.2. Due to pressure:

Often seen in traffic accidents, house collapses, mine collapses...

3. Pathological anatomical lesions:

3.1. Damage to the wall of the uterus:

There are many forms of damage to the Ohem wall such as abrasions and skin tears; contusions, hematomas of the Ohem wall muscles, and possible tearing of the fascia in the anterior Dhem wall causing a rupture. The common characteristic of the damage is that there is no communication between the Ohem cavity and the outside.

3.2. Damage to abdominal organs:

3.2.1. Solid organs:

Injuries to solid organs such as ruptured liver or spleen cause massive bleeding into the abdominal cavity, causing symptoms of acute blood loss, but there may also be non-massive blood loss due to small ruptures or subcapsular ruptures. Trauma to the mid-abdomen can cause pancreatic injury, which also causes intra-abdominal bleeding.

3.2.2. Hollow organs:

Trauma can cause bruising, rupture or perforation of hollow organs (stomach, duodenum, small intestine, colon, bladder, gallbladder) - digestive fluids, feces, bile or urine will enter the abdominal cavity, manifesting acute peritonitis syndrome.

3.2.3. Possible combined injuries:

Many other organs can also be damaged: Traumatic brain injury, spinal cord, chest, abdomen, fractures of limbs or pelvis, damage to large blood vessels....

4. General clinical manifestations:

4.1. Ask the patient or family member carefully when the patient comes to the hospital:

Ask carefully to know about the time, agent, mechanism of injury and symptoms that appear after the injury: abdominal pain, pain in the hypochondrium, vomiting, hematuria, state of consciousness, etc. that appear after the injury.

4.2. Clinical manifestations that can be detected after examination:

4.2.1. Shock:

Shock following abdominal trauma may be due to severe pain or acute blood loss. If resuscitation fails, internal bleeding is usually the cause.

Clinical manifestations: pale skin, pale mucous membranes, cold nose and extremities, rapid shallow breathing, rapid pulse, low arterial blood pressure, agitation, fear and anxiety or vice versa: slowness, indifference to the outside world, eyes open looking into the distance.

4.2.2. Internal bleeding:

Intra-abdominal bleeding should usually be considered when:

- When treated for shock, the patient improved, then showed signs of shock again.

- There was no shock when admitted to the hospital, but after a few hours shock appeared.

- Abdominal pain spreading far from the wound site, spreading throughout the abdomen

- Distention, peritoneal sensation in the neck, dullness in both pelvic fossae.

- Rectal examination revealed Douglas swelling and pain.

- The number of HC, HST ratio and hematocrite decreased.

- XQ: low abdominal opacity.

- Abdominal puncture showed non-coagulated blood.

4.2.3. Peritonitis due to perforation of hollow viscus:

- Ohem pain immediately after injury, spontaneous pain, continuous pain spreading throughout the abdomen, pain increases when changing position.

- Vomiting: Due to peritoneal irritation, the patient vomits. Some patients only feel nauseous, while others vomit blood if the injury is in the stomach or duodenum.

- Abdominal wall stiffness: newly perforated patient comes to the clinic with abdominal wall stiffness, if late there are clear signs of peritoneal sensation.

- Constipation and defecation

- Stomach gradually bloated.

- TR has the “Douglas cry”

- Usually the patient lies curled up (Mondor)

- Unprepared Ohm's scan shows air crescent under the diaphragm on one or both sides.

5. Diagnosis of organ damage:

5.1. Splenic rupture:

- Trauma to the left hypochondrium, left chest bottom, often with fracture of the last rib in the left chest area.

- Pain in the left flank spreading to the shoulder and left back.

- Examination detected internal bleeding syndrome.

- Fainting or obvious shock after injury.

- Abdominal distension, peritoneal sensation, dullness on percussion from the left costal margin down to the left iliac fossa.

- Douglas rectal examination is painful.

- Unprepared abdominal X-ray, standing: Left diaphragm pushed up, stomach pushed to the right, left colon angle pushed down, spleen opacity widened.

- Abdominal puncture with non-coagulated blood

- Ultrasound diagnosed spleen rupture.

Sometimes the spleen ruptures in 2 stages: Stage 1: subcapsular splenic rupture - stage 2: the hematoma ruptures causing blood to spill into the abdominal cavity. The patient has a relatively quiet period between the 2 stages.

5.2. Liver rupture:

Direct trauma to the liver area - right chest base. After the trauma, the patient has pain in the right chest base and right hypochondrium, there may be a fracture of the last rib in the right chest area.

- The whole body has symptoms of hemorrhagic shock.

- Examination revealed internal bleeding syndrome.

- Diffuse stiffness in the right half of the abdomen.

- Percussion of the right lower rib

- Rectal examination: Donglas pain.

- Abdominal X-ray: Enlarged liver, right diaphragm pushed up,

- Abdominal puncture revealed non-coagulated blood.

- Ultrasound diagnosed liver rupture.

In some cases of atypical liver rupture, subcapsular rupture will be difficult to diagnose (Stage 1 subcapsular liver rupture - stage 2: the hematoma ruptures causing blood to spill into the abdominal cavity). If possible, a CT scan should be performed to determine the injury.

5.3. Kidney rupture:

The kidney is a retroperitoneal organ that is vulnerable and can be present in the setting of abdominal trauma.

Due to severe trauma to the flank-lumbar fossa. After the trauma, the patient had severe pain in the Dhem area, hematuria, and examination revealed abdominal stiffness on the injured side.

- If there is a lot of blood loss, the patient may go into shock.

- Diagnostic ultrasound. Should Dhem Dhem and chest to determine the lesion

combination.

5.4. Damage though.

- Mid-abdominal trauma. Pancreas bruised and bleeding

- Signs of peritonitis - Ohem's wall stiffness

- Abdominal X-ray is of little value.

- Abdominal puncture showed non-coagulated blood.

5.5. Bladder rupture:

The bladder is located under the peritoneum, not part of the abdominal cavity but is vulnerable and must be considered in the context of abdominal trauma.

The cause is due to trauma to the lower abdomen or pelvic trauma, when the bladder is full of urine, often with pelvic fracture. It can be:

+ Intraperitoneal bladder rupture: Patients with peritonitis syndrome:

- Bladder catheterization with no urine or little urine mixed with blood.

- No bladder bridge

+ Extraperitoneal bladder rupture.

- Subcutaneous hematoma above the pubic area (pseudobladder)

- Clearing urine mixed with blood.

5.6. Stomach:

Dhem injury causes gastric rupture, often in patients after a full meal.

- Vomiting red blood mixed with food.

- Examination showed signs of peritonitis, abdominal wall stiffness, and a gastric tube.

blood.

- If there is a lot of bleeding, the patient shows signs of blood loss.

- Abdominal X-ray without preparation ASP (Abdomen sans préparation) has

image of air crescent under the diaphragm.

5.7. Duodenum:

Duodenal rupture is rare. Symptoms:

- Severe abdominal pain and abdominal wall stiffness upon perforation. Generalized peritonitis.

- Unprepared abdominal X-ray shows diaphragmatic air crescent.

- Extraperitoneal rupture: Usually only detected during surgery (pneumothorax and

retroperitoneal bile).

5.8. Small intestine:

Mid-abdominal trauma is common. Hematoma, bruising, rupture, and separation of intestinal loops. Injuries are most common in the first loop of the jejunum and the last loop of the ileum.

- After the injury, the patient had continuous pain throughout the Ohem, vomiting, and constipation.

- Neck stiffness, peritoneal sensation.

- Unprepared abdominal X-ray: Air crescent under the diaphragm.

Sometimes the injury is a location (intestinal wall or mesentery) that is bruised, has a hematoma, and a few days later the intestine becomes necrotic and perforated, causing stage 2 peritonitis.

5.9. Colon:

- In abdominal trauma, the colon is rarely perforated or ruptured, but often has diffuse hematoma in the colon wall and retroperitoneum. If the colon ruptures, the patient is often severely ill due to fecal peritonitis.

5.10. Mesentery, omentum, diaphragm:

- The omentum is rarely damaged, if damaged it often causes mesenteric hematoma.

- Mesenteric tears cause severe bleeding. If the tear is transverse, the corresponding intestinal segment is often damaged (ischemia, necrosis).

- Diaphragmatic rupture is often caused by severe trauma, often combined with chest and abdominal trauma, tears, and diaphragmatic rupture causing bleeding, wide tears causing herniation of the intestinal loops, stomach up into the chest causing compression of lung parenchyma, severe difficulty breathing. Usually detected through chest X-ray.

6. Treatment:

6.1. Shock resistance:

- Restore lost circulatory volume with fluids followed by blood transfusion of the same group.

- Prevent respiratory failure for patients with oxygen 3-51/1 minute.

- Support, support.

- Patients with severe bleeding need both resuscitation and surgery.

6.2. Surgery:

Need to examine carefully, monitor closely to detect organ damage or not.

Surgery is indicated when:

+ A definite diagnosis is that there is damage to the abdominal organs.

+ Suspected and unable to rule out the possibility of organ damage. When surgery is indicated, it is usually handled according to the following principles:

- Pain relief by endotracheal anesthesia.

- Open the abdomen by a white line above the navel. When it is necessary to expand, depending on the type of injury, it will be more convenient.

- Carefully and systematically examine all organs to avoid missing any injuries.

6.2.1. If there is blood in the abdomen:

Seeing a lot of thin blood mixed with blood clots in the abdomen is usually due to rupture of a solid organ. It is necessary to quickly drain all the blood, use a gauze to remove all the blood clots, check to detect damaged organs, then depending on each damaged organ, there is an appropriate treatment:

- Spleen: Traumatic spleen rupture is still often treated by splenectomy. Only in a few places with conditions can surgeons perform a partial splenectomy or spleen preservation when the injury is mild. However, in emergency conditions, the top priority is to save the patient's life, so in surgery, the spleen is often removed to stop bleeding quickly. And to ensure more certainty.

- Liver: Maximum preservation by:

+ Suture to stop bleeding of liver wound.

+ Localized sub-lobar crush: partial liver resection.

+ Associated biliary tract injury: cholecystostomy can be performed using a Kehr drainage tube or gallbladder drainage.

- Pancreas: Maximum preservation

+ Crushed tail of pancreas: remove tail of pancreas and cut spleen + drainage.

+ Suture tip: Suture + drainage.

+ Simple injuries only need sutures + drainage.

- Kidney:

+ Hemostasis suture 4- drainage.

+ Kidney removal is a last resort (in case of too much crushing or broken kidney pedicle).

- Hanging tag: