1. What is hypertonic saline?

Show answer
Normal saline is 0.9% sodium chloride. Hypertonic saline is 7.5% sodium chloride (eight times as concentrated as normal saline).

KEY POINTS: ION CONCENTRATIONS IN CRYSTALLOID SOLUTIONS

1. ½ NS or 0.45% NaCl: 77 mEq of Na+, 77 mEq of Cl-
2. NS or 0.9% NaCl: 154 mEq of Na+, 154 mEq of Cl-
3. Hypertonic NS or 7.5% NaCl: 1283 mEq of Na+, 1283 mEq of Cl-
4. Lactated Ringer’s: 130 mEq of Na+, 110 mEq of Cl-, 38 mEq of lactate, 4 mEq of K+, and 3 mEq Ca+

2. What is hypertonic saline good for?

Show answer
Resuscitation. The initial hypothesis was that a little hypertonic saline would pull extravascular water into the intravascular compartment, rapidly restoring volume. It now appears that an osmotic jolt (even a transient jump from 140 to 180 mOsm) would pacify circulating neutrophils so that they do not stick to the endovasculature and provoke posttraumatic inflammation.

3. Is hypertonic saline good for anything else?

Show answer
Pacification of “primed” neutrophils should decrease the risk of posttraumatic multiple organ failure.

4. How do you convert 1 g of sodium into milliequivalents (mEq)?

Show answer
Divide by the atomic weight of sodium:

1g (1000 mg) of sodium ÷ 23 = 43.5 mEq

5. How many mEq of sodium are in 1 teaspoon of salt?

Show answer
104 mEq (or 2400 mg).

6. How many mEq of sodium are in an 8-oz bottle of Gatorade?

Show answer
5 mEq.

7. How much does a 40-lb block of salt cost?

Show answer
$3.40 at the feed store.

8. What is the electrolyte content of IV fluids?

Show answer
See Table 7-1.

Table 7-1. ELECTROLYTE CONTENT OF INTRAVENOUS FLUIDS

*Lactate is converted immediately to bicarbonate.

9. How do these concentrations relate to body fluid and electrolyte compartments?

Show answer
See Table 7-2.
Table 7-2. ELECTROLYTE CONCENTRATIONS IN BODY FLUIDS

10. What are the daily volumes (mL/24 h) and electrolyte contents (mEq/L) of body secretions for a 70-kg medical student?

Show answer
See Table 7-3.
Table 7-3. DAILY VOLUMES AND ELECTROLYTE CONTENTS OF BODY SECRETIONS

*See question 6.

11. Are sweat glands responsive to aldosterone? Can they be trained?

Show answer
Yes and yes. Archie Bunker’s sweat contains 100 mEq/L sodium, whereas an Olympic marathon runner retains sodium (sweat sodium may be as low as 25 mEq/L).

12. Is Gatorade really just flavored athlete’s sweat?

Show answer
Yes.

13. What are the daily maintenance fluid and electrolyte requirements for a 70-kg medical student?

14. Does the routine postoperative patient require IV sodium or potassium supplementation? Routine serum electrolyte testing?

Show answer
No and no.

15. Can a patient with a good heart and kidneys overcome all but the most woefully incompetent fluid and electrolyte management?

Show answer
Yes.

16. Can one throw a healthy medical student into congestive heart failure by IV infusion of 100 mL of 5% dextrose in saline solution per kg per hour?

Show answer
No. One will simply be ankle-deep in urine.

17. What is subtraction alkalosis?

Show answer
Vigorous nasogastric suction of a patient with a lot of gastric acid eliminates hydrochloric acid, leaving the patient alkaloti

c.
18. Which electrolyte is most useful in repairing a hypokalemic metabolic alkalosis?

Show answer
Chloride.

19. List the best indicators of a patient’s volume status.

Show answer

* Heart rate
* Blood pressure
* Urine output
* Big-toe temperature

20. Does a warm big toe indicate a hemodynamically stable patient?

Show answer
Most likely. The vascular autoregulatory ability of a young healthy patient is huge. The carotid and coronary circulations are maintained until the bitter end. Conversely, if the patient’s big toe is warm and perfused, the patient is stable.

21. What is the minimal adequate postoperative urine output?

Show answer
0.5 mL/kg/h.

22. What is a typical postoperative urine sodium?

Show answer
< 20 mEq/L.

23. Why?

Show answer
Surgical stress prompts mineralocorticoid (aldosterone) secretion so that the normal kidney retains sodium.

24. Explain paradoxical aciduria.

Show answer
Postoperative patients, by virtue of nasogastric suction (loss of gastric acid), blood transfusions (the citrate in blood is converted to bicarbonate), and hyperventilation (decreased Pco2), are typically alkalotic. Patients also are stressed, and their kidneys retain sodium and water. The renal tubules must exchange some other cations for the retained sodium. The kidney chooses to exchange potassium and hydrogen ions. Even in the face of systemic alkalosis, the postoperative kidney absorbs sodium and excretes hydrogen ions, producing a paradoxical aciduria.
KEY POINTS: MECHANISMS OF PARADOXICAL ACIDURIA

1. Nasogastric suction or refractory vomiting results in loss of gastric acid.
2. Physiologic stress promotes renal retention of sodium and water.
3. To hold on to sodium, the kidney must release other cations (potassium and hydrogen).
4. Counterintuitively, the kidney will release hydrogen ions to keep sodium, resulting in acidic urine.

25. What is third spacing?

Show answer
Hypotension and infection prime neutrophils (CD11 and CD18 receptor complexes), promoting adherence to vascular endothelial cells. Subsequent activation of adherent neutrophils spews out proteases and toxic superoxide radicals, blowing big holes in the vascular lining. Water and plasma albumin leak through the holes. The volume pulled out of the vascular space into the third space of the interstitial and hollow viscus (gut) creates relative hypovolemia and requires additional fluid replacement.

26. What is a Lasix sandwich?

Show answer
25% albumin followed by 20 mg of furosemide (Lasix) IV. If the patient is edematous, the IV albumin theoretically sucks water osmotically out of the interstitial third space. As the excessive water enters the vascular compartment, Lasix produces a healthy diuresis. In most intensive care unit patients, however, the infused albumin rapidly equilibrates across the damaged vascular endothelium. No additional water is pulled into the blood volume. Although surgeons often order Lasix sandwiches, they probably work only in healthy patients who do not need them.

References
BIBLIOGRAPHY
1. Brown MD: Evidence-based emergency medicine: Hypertonic versus isotonic crystalloid for fluid resuscitation in critically ill patients. Ann Emerg Med 40:113-114, 2002. Medline Similar articles Full article
2. Bunn F, Roberts I, Tasker R, Akpa E: Hypertonic versus isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev (1):CD002045, 2002. Full article
3. Greaves I, Porter KM, Revell MP: Fluid resuscitation in pre-hospital trauma care: A consensus view. J R Coll Surg Edinb 47:451-457, 2002. Medline Similar articles
4. Traber DL: Fluid resuscitation after hypovolemia. Crit Care Med 30:1922, 2002. Medline Similar articles

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1. What is the physiologic role of the spleen?

Show answer
In fetal development, the spleen serves as a major site for hematopoiesis. In early childhood the spleen produces immunoglobulin M (IgM) and tuftsin. The spleen also functions as a filter, allowing resident macrophages to remove abnormal red blood cells (RBCs), cellular debris, and encapsulated and poorly opsonized bacteria.

2. What injury patterns are associated with splenic trauma?

Show answer
Direct blunt force, deceleration, and compression to the left torso. Think spleen after a motor vehicle accident or fall: lower rib fractures, left side-only rib fractures, and high-energy transfer (big hits) increase the probability of splenic injury.

3. What are the signs and symptoms of splenic injury?

Show answer
The main sign is pain in the left upper quadrant. This is produced by stretching the splenic capsule. Peritoneal irritation (rebound tenderness) is caused by extravasated blood (blood is very irritating). Vital signs vary depending on associated blood loss and are not specific for injuries to the spleen. Unfortunately, a large number of patients with a significant splenic injury exhibit no signs or symptoms at all.

4. What studies can help in diagnosing splenic trauma?

Show answer
Ultrasound (US) can be performed in the emergency department and can rapidly identify as little as 200 mL fluid/blood. When US is not available, diagnostic peritoneal lavage (DPL) is an accurate and sensitive measure of intraabdominal bleeding.
Hemodynamically stable patients permit more thorough evaluations. Although US is extremely sensitive for detecting intraabdominal bleeding, computed tomography (CT) not only can detect and quantify intraabdominal blood but also can characterize specific intraabdominal injuries.

5. How are splenic injuries classified, and why is that important?

Show answer
Management is governed by the hemodynamic status of the patient, but therapy is also influenced by the CT grade of splenic injury. Nonoperative management is most successful in grades I-III, whereas operative intervention is often required for grade IV injuries. Grade V injuries demand prompt operative intervention. (See Table 26-1.)

6. Do splenic injuries require laparotomy?

Show answer
No. Nonoperative management is successful in approximately 95% of patients with grades I-III. Hemodynamically stable patients with evidence of ongoing bleeding (requiring transfusion) may be treated by selective arterial embolization if a bleeding site is identified on angiography.

7. What are contraindications to nonoperative management of splenic injuries?

Show answer

* Hemodynamic instability
* Persistent coagulopathy
* Additional intraabdominal injury requiring operative intervention
. GRADES OF SPLENIC INJURY

8. What is the failure rate of nonoperative management of splenic injury?

Show answer
Any patient with signs of hemodynamic instability, persistent bleeding, worsening pain or tenderness, or progressive injury by CT scanning has failed nonoperative management. Approximately 60% of all splenic injuries can be managed nonoperatively with a failure rate of 12%. Factors that predict nonoperative failure include multiple injuries, grade III-V spleen injuries, age > 55 years, and blood traunsfusion.
KEY POINTS: EXPECTANT MANAGEMENT OF SPLENIC INJURIES

1. Nonoperative management is successful in 95% of grades I-III injuries.
2. 60% of all splenic injuries are managed nonoperatively, with a 12% failure/conversion rate.
3. Factors that predict failure/conversion to operative treatment include injury > grade III, age > 55 years, and blood transfusion requirements.
4. Patients with evidence of ongoing bleeding (e.g., contrast “blush” on CT or ongoing transfusion requirements) may be managed with selective arterial embolization.

9. What is delayed rupture of the spleen?

Show answer
This is a rare complication that occurs in < 1% of patients with a splenic injury. Delayed splenic rupture should be distinguished from a delay in diagnosis of splenic injury and rupture of a known splenic injury. True delayed splenic rupture occurs > 48 hours in a patient with a history of abdominal trauma and no overt clinical evidence of intraabdominal injury on initial presentation.

10. What are the general principles of operative management of the injured spleen?

Show answer
The first priority is to control bleeding. This can usually be accomplished by packing and manual compression of the spleen. If successful, the abdomen is then thoroughly explored for other injuries. Complete mobilization of the spleen by division of the splenocolic, splenorenal, phrenosplenic, and gastrosplenic ligaments is required for complete assessment of the spleen. The short gastric vessels can be ligated with division of the gastrosplenic ligament. Repair of the spleen can be accomplished by application of hemostatic agents, direct pledgeted suture repair of the splenic parenchyma, partial splenectomy, and construction of a “splenic wrap” using absorbable mesh. If splenectomy is required, the splenic artery and vein should be ligated individually prior to removing the spleen.

11. What early complications arise after splenectomy?

Show answer
Bleeding, acute gastric dilatation, gastric perforation, pancreatitis (the splenic artery courses along the top of the pancreas), and subphrenic abscess.

12. What is splenic autotransplantation?

Show answer
Autotransplantation is accomplished by implanting splenic tissue parenchymal slices into pouches created in the gastrocolic omentum.

13. Does splenic autotransplantation preserve splenic function?

Show answer
Autotransplantion after splenectomy is controversial. At least 30% of the original splenic mass is needed to provide normal function. After autotransplantation, IgG and IgM levels are increased in response to pneumococcal vaccine compared with patients after splenectomy alone.

14. Does postsplenectomy leukocytosis predict infection?

Show answer
Elevations in white blood cell (WBC) count and platelet count (PC) after splenectomy are a common physiologic event. After the fourth postoperative day, however, a WBC > 15 x 103 and a PC/WBC < 20 are highly associated with sepsis and should not be confused with the physiologic response to splenectomy.

15. Should a follow-up CT scan be performed after nonoperative management of splenic injuries before patient discharge?

Show answer
No. Most patients who fail nonoperative management do so within 5 days and will exhibit hemodynamic evidence of ongoing hemorrhage. However, follow-up CT should be performed for grade III and IV injuries at 4-6 weeks before getting back to vigorous physical activity.

16. What is OPSS, and how is it prevented?

Show answer
Overwhelming post splenectomy sepsis (OPSS) is a devastating bacteremia (typically encapsulated bacteria) that occurs in 2% of patients after splenectomy. The risk of OPSS is greatest when splenectomy is performed during infancy. The most common organisms are pneumococcus (50%), meningococcus, Escherichia coli, Haemophilus influenzae, staphylococcus, and streptococcus. Although rare, OPSS carries a mortality rate of 75% and has spurred interest in splenic preservation. OPSS is primarily prevented by postoperative vaccination. Pneumococcal, meningococcal, and Haemophilus flu vaccines should be given 2 weeks after splenectomy and are recommended every 5 years. Sepsis can occur despite vaccination; consequently, long-term prophylaxis with oral penicillin is recommended for children.

References
WEB SITES

1. http://www.east.org/tpg/bluntabd.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0506.htm

BIBLIOGRAPHY
1. Cocanour CS, Moore FA, Ware DN, et al: Delayed complications of nonoperative management of blunt adult splenic trauma. Arch Surg 133:619-624, 1998. Medline Similar articles Full article
2. Leemans R, Manson W, Snijder JA, et al: Immune response capacity after human splenic autotransplantation: Restoration of response to individual pneumococcal vaccine subtypes. Ann Surg 229:279-285, 1999. Medline Similar articles Full article
3. Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver (1994 revision). J Trauma 38:323-324, 1995.
4. Shatz DV: Vaccination practices among North American trauma surgeons in splenectomy for trauma. J Trauma 53:950-956, 2002. Medline Similar articles Full article
5. Toutouzas KG, Velmahos GC, Kaminski A, et al: Leukocytosis after posttraumatic splenectomy: A physiologic event or sign of sepsis? Arch Surg 137:924-928, 2002. Full article
6. Uecker J, Pickett C, Dunn E: The role of follow-up radiographic studies in nonoperative management of spleen trauma. Am Surg 67:22-25, 2001. Medline Similar articles

7. Are vital signs important?

Show answer
Yes. They are vital. If heart rate and blood pressure are on the wrong side of 100 (heart rate > 100 beats/min, systolic blood pressure < 100 mmHg), watch out! Tachypnea (respiratory rate >16) reflects either pain or systemic acidosis. Fever may develop late, particularly in the immunosuppressed patient who may be afebrile in the face of florid peritonitis.

8. What is rebound?

Show answer
The peritoneum is well innervated and exquisitely sensitive. It is not necessary to hurt the patient to elicit peritoneal signs. Depress the abdomen gently and release. If the patient winces, the peritoneum is inflamed (rebound tenderness).

9. What is mittelschmerz?

Show answer
Mittelschmerz is pain in the middle of the menstrual cycle. Ovulation frequently is associated with intraperitoneal bleeding. Blood irritates the sensitive peritoneum and hurts.

10. What do bowel sounds mean?

Show answer
If something hurts (e.g., a sprained ankle), the patient tends not to use it. Inflamed bowel is quiet. Bowel contents squeezed through a partial obstruction produce high-pitched tinkles. Bowel sounds are notoriously unreliable, however.

11. Explain the significance of abdominal distention.

Show answer
Distention may derive from either intraenteric or extraenteric gas or fluid (worst of all, blood). Abdominal distention is always significant and bad.

12. Is abdominal palpation important?

Show answer
Yes. Remember, the patient is (or should be) the surgeon’s friend. There is no need to cause pain. Palpation guides the surgeon to the anatomic zone of most tenderness (usually the diseased area). It is best to start palpation in an area that does not hurt. Rectal (test stool for blood) and pelvic examinations localize pathology further.

13. What is Kehr’s sign?

Show answer
The diaphragm and the back of the left shoulder enjoy parallel innervation. Concurrent left upper quadrant and left shoulder pain indicate diaphragmatic irritation from a ruptured spleen or subdiaphragmatic abscess.

14. What is a psoas sign?

Show answer
Irritation of the retroperitoneal psoas muscle by an inflamed retrocecal appendix causes pain on flexion of the right hip or extension of the thigh.

1. How often is the liver injured in trauma?

Show answer
The liver is both big and central, so it is an easy target.

2. Do the liver and spleen respond similarly to injury?

Show answer
No. The liver has a unique ability to establish spontaneous hemostasis even with extensive injuries. For this reason, the majority of liver injuries in hemodynamically stable patients can be managed nonoperatively. In contrast, many splenic fractures continue to bleed; therefore, a greater percentage require operative intervention.

3. What are the determinants of mortality after acute liver injury?

Show answer
The mechanism of injury and the number of associated abdominal organs injured determine mortality. The mortality for stab wounds to the liver is 2%; for gunshot wounds, 8%; and for blunt injuries, 15%. The mortality rate for isolated grade III hepatic injuries is 2%; for grade IV, 20%; and for grade V, 65%. Retrohepatic vena cava injuries carry mortality rates of 80% for penetrating trauma and 95% for blunt trauma.

4. What history and physical signs suggest acute liver injury?

Show answer
Any patient sustaining blunt abdominal trauma with hypotension must be assumed to have a liver injury until proven otherwise. Specific signs that increase the likelihood of hepatic injury are contusion over the right lower chest, fracture of the right lower ribs (especially posterior fractures of ribs 9-12), and penetrating injuries to the right lower chest (below the fourth intercostal space, flank, and upper abdomen). Physical signs of hemoperitoneum may be absent in as many as one third of patients with significant hepatic injury.

5. What diagnostic tests are helpful in confirming acute liver injury?

Show answer
A focused abdominal sonography for trauma (FAST) examination can detect or rule out hemoperitoneum and pericardial tamponade. Diagnostic peritoneal lavage (DPL) is sensitive for hemoperitoneum (99%). Ultrasound is highly sensitive in identifying > 200 mL of intraperitoneal fluid. It is noninvasive and may be repeated at frequent intervals, but it is relatively poor for staging liver injuries. Abdominal computed tomography (CT) scan currently is used only in hemodynamically stable patients who are candidates for nonoperative management. The major shortcoming of CT is the relatively poor correlation between hepatic CT staging and subsequent risk of hemorrhage.

6. What is the role of hepatic angiography and radionuclide biliary excretion scans in the diagnosis of liver injury?

Show answer
Selective hepatic artery embolization is effective therapy for hepatic arterial bleeding, both for avoidance of surgery and for recurrent postoperative bleeding.

1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?

Show answer

1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home

2. Which is the most dangerous course?

Show answer
To send the patient home.

3. Is it important to make the diagnosis in the emergency department?

Show answer
No. Frequently time spent confirming a diagnosis in the emergency department is lost to inhospital resuscitation or treatment in the operating room. The only patient who needs a relatively firm diagnosis is a patient who is to be sent home.

4. If the essential goal is not to make the diagnosis, what should the surgeon do?

Show answer

1. Resuscitate the patient. Most patients do not eat or drink when they are getting sick. Most patients are depleted of at least several liters of fluid. Fluid depletion is worse in patients with diarrhea or vomiting.
2. Start a big IV line.
3. Replace lost electrolytes (see Chapter 7).
4. Insert a Foley catheter.
5. Examine the patient (frequently).

5. Are symptoms and signs uniquely misleading in any groups of patients?

Show answer
Yes. Watch out for the following groups:

* The very young, who cannot talk.
* Diabetics, because of visceral neuropathy.
* The very old, in whom, much as in diabetics, abdominal innervation is dulled.
* Patients taking steroids, which depress inflammation and mask everything.
* Patients with immunosuppression (a heart or kidney transplant patient may act cheerful even with dead or gangrenous bowel).

6. Summarize the history needed.

Show answer

1. The patient’s age. Neonates present with intussusception; young women present with ectopic pregnancy, pelvic inflammatory disease, and appendicitis; the elderly present with colon cancer, diverticulitis, and appendicitis.
2. Associated problems. Previous hospitalizations, prior abdominal surgery, medications, heart and lung disease? An extensive gynecologic history is valuable; however, it is probably safer to assume that all women between 12 and 40 years old are pregnant.
3. Location of abdominal pain. Right upper quadrant: gallbladder or biliary disease, duodenal ulcer. Right flank: pyelonephritis, hepatitis. Midepigastrium: duodenal or gastric ulcer, pancreatitis, gastritis. Left upper quadrant: ruptured spleen, subdiaphragmatic abscess. Right lower quadrant: appendicitis (see Chapter 37), ectopic pregnancy, incarcerated hernia, rectus hematoma. Left lower quadrant: diverticulitis, incarcerated hernia, rectus hematoma. Note: Cancer, unless it obstructs (colon cancer), and bleeding (diverticulosis) typically do not hurt.
4. Duration of pain. The pain of a perforated duodenal ulcer or perforated sigmoid diverticulum is sudden, whereas the pain of pyelonephritis is gradual and persistent. The pain of intestinal obstruction is intermittent and crampy. Note: Although the surgeon is rotating through a gastrointestinal service, the patient may not know this and may present with urologic, gynecologic, or vascular pathology.

1. What elements of the history are important in evaluating a patient with suspected blunt abdominal trauma (BAT)?

Show answer
First, the mechanism of injury (e.g., motor vehicle collision, automobile-pedestrian accident, fall) is important. In motor vehicle accidents, note the position of the victim in the car, velocity of impact (high, moderate, low), type of accident (front, lateral, or rear impact; side swipe; rollover), and type of restraint used (shoulder restraint, air-bag, lap belt). Information about damage to the vehicle, such as a broken windshield or bent steering wheel, may raise suspicion of cervical and chest injuries. In a fall, it is important to note the distance fallen and the site of anatomic impact. Vertical landing on the feet or in a sitting position causes a different pattern of injury than lateral landing on the side. Serial vital signs and mental status are always important.

2. Is physical examination accurate in the diagnosis of intraabdominal injury?

Show answer
No. The examination results may be normal in up to 50% of patients with acute intraabdominal bleeding. Signs of intraabdominal injury include abrasions and contusions over the lower chest and abdomen; subcutaneous emphysema or palpable rib fracture; clinically evident pelvic fracture; abdominal pain, tenderness, guarding, or rigidity; blood in the urine or urethral meatus; high-riding prostate or blood on rectal examination; and microscopic hematuria.
3. Which organs are most frequently injured in BAT?

4. What diagnostic studies are helpful in BAT?

Show answer

1. Ultrasound: reliably identifies peritoneal fluid (blood) and pericardial fluid but may miss up to 25% of isolated solid organ injuries.
2. Computed tomography (CT) scan: identifies the presence and severity of solid organ injury (liver and spleen), detects intraabdominal air and fluid (blood, mucus, urine), and aids in evaluation of pelvic fractures. CT scanning can also identify bowel, pancreatic, renal, and bladder injuries.
3. Diagnostic peritoneal lavage (DPL): grossly positive DPL (> 10 mL blood returned by aspiration of the catheter) indicates significant hemoperitoneum. Positive by cell count after infusion of 1 L of crystalloid fluid (> 100,000 red blood cells/mm3, presence of bile or fibers) indicates intraabdominal bleeding, injury to hollow viscus, or hepatobiliary system injury. Lavage fluid exiting through a chest tube or urinary catheter indicates diaphragmatic or bladder injury.

5. How has the availability of ultrasound (US) changed the initial evaluation of BAT?

Show answer
The focused abdominal sonography for trauma (FAST) examination has largely supplanted the DPL. The FAST examination can be performed in a hemodynamically unstable patient during the early secondary survey with immediate transfer to the operating room when hemoperitoneum is identified. CT scan is safe in the hemodynamically stable patient. DPL is still useful when US is equivocal or not available and for evaluation of hollow organ injury.

6. How is hollow organ injury diagnosed?

Show answer
CT findings include peritoneal fluid without solid organ injury, extravasation of oral contrast into the peritoneal cavity, and free intraabdominal air. Suggestive signs include mesenteric stranding and hematoma. Peritoneal lavage results suggestive of hollow organ injury include elevated amylase, alkaline phosphatase, or biliribun levels and the presence of particulate matter.
KEY POINTS: USEFUL DIAGNOSTIC MODALITIES IN BAT

1. Primary and secondary surveys are crucial, but further diagnostic testing is required in most patients.
2. FAST: reliably identifies intraabdominal and intrapericardial fluid but is poor at hollow viscus evaluation.
3. DPL: effective for evaluation of hemoperitoneum and a useful adjunct along with FAST exam.
4. CT: excellent modality with 99.97% negative predictive value for BAT.

7. What are the indications for urgent operation in a patient with BAT?

Show answer
Any hemodynamically unstable patient who exhibits significant hemoperitoneum (by US or DPL) requires emergency laparotomy. Other indications for urgent laparotomy include free intraabdominal air and evidence of hollow viscus injury.

8. How does time in the emergency department (ED) impact the mortality of patients requiring emergent operation for BAT?

Show answer
The probability of death from trauma is related to both the extent of hypotension and the interval from the time of injury to definitive surgery. An estimated increase in mortality of 1% is incurred for every 3 minutes spent in the ED up to 90 minutes.

9. What is the role of angiographic embolization?

Show answer
Angiographic embolization may be effective for hemorrhage control in hemodynamically stable patients. Favorable embolization sites include liver, spleen, and kidney injuries; lumbar arteries with retroperitoneal hemorrhage; and pelvic blood vessels associated with pelvic fracture.

10. What is the “bloody viscus cycle”?

Show answer
The bloody viscus cycle is a syndrome of hypothermia, acidosis, and coagulopathy that occurs with profound hemorrhagic shock and massive transfusion. It represents a circular cascade of events in which severe hemorrhagic shock accompanied by metabolic failure provokes a coagulopathy that exacerbates further bleeding.

11. What is a staged or abbreviated laparotomy (damage control surgery)?

Show answer
Staged laparotomy is terminated before all definitive procedures are completed with the intent to return to the operating room to complete the operation at a later (and safer) time. The purpose of this approach is to delay additional surgical stress until the patient is in a more favorable physiologic state. The objectives of the initial operation become to (1) arrest bleeding and correct coagulopathy; (2) limit peritoneal contamination and the secondary inflammatory response (to control gastrointestinal spillage); and (3) enclose the abdominal contents to protect viscera and limit heat, fluid, and protein loss from an open abdomen.

12. When is staged laparotomy used in trauma patients?

Show answer

* Inability to achieve hemostasis because of recalcitrant coagulopathy (pack the bleeding)
* Inaccessible major venous injury (retrohepatic caval injury)
* Demand for control of a life-threatening extraabdominal (e.g., head or thoracic) injury
* Inability to close the abdominal incision because of extensive visceral edema
* Need to reassess the abdominal contents because of questionable viability at the time of the initial operation

References
WEB SITE
http://www.east.org/tpg/bluntabd.pdf

BIBLIOGRAPHY
1. Branney SW, Moore EE, Cantrill SV, et al: Ultrasound based key clinical pathway reduces the use of hosptial resources for the evaluation of blunt abdominal trauma. J Trauma 42:1086-1090, 1997. Medline Similar articles Full article
2. Burch JM, Denton JR, Noble RD: Physiologic rationale for abbreviated laparotomy. Surg Clin North Am 77:779-782, 1997. Medline Similar articles
3. Clarke JR, Trooskin SZ, Doshi PJ, et al: Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 52:420-425, 2002. Similar articles Full article
4. Davis KA, Fabian TC, Croce MA, et al: Improved success in management of blunt splenic injuries: Embolization of splenic artery pseudoaneurysms. J Trauma 44:1008-1013, 1998.
5. Livingston DH, Lavery RF, Passannante MR, et al: Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy. Am J Surg 182:6-9, 2001. Medline Similar articles Full article
6. Miller MT, Pasquale MD, Bromberg WJ, et al: Not so fast. J Trauma 54:52-59, 2003. Medline Similar articles Full article

1. What is the most common type of renal trauma in the United States, blunt or penetrating?

Show answer
Blunt, by far.

2. Do most kidney injuries require surgery?

Show answer
No. Fewer than 2% of blunt injuries require surgery, and many penetrating injuries can also be treated nonoperatively.

3. Are pediatric kidneys more susceptible to major injury?

Show answer
Yes. Because of children’s weaker abdominal muscles, less-ossified thoracic cage, decreased perirenal fat, and increased renal size in relation to the rest of the body, the risk for renal injury is greater in the pediatric population.

4. When should potential renal trauma be investigated?

Show answer
All blunt trauma patients with gross hematuria or with microscopic hematuria and shock (systolic blood pressure < 90 mmHg) should be closely examined. Penetrating injuries with any degree of hematuria should be imaged. For pediatric patients, liberal use of studies is advisable. When children spill < 50 red blood cells (RBCs) per high-powered field (hpf) on microscopic urinalysis, significant renal injury is rare. Furthermore, shock is not a useful guide in children.

5. When does one suspect renal trauma?

Show answer
The mechanism of injury, physical examination (e.g., flank ecchymosis, location of penetrating wounds), and associated injuries (e.g., rib fractures) should raise suspicion of renal trauma. Although the degree of hematuria does not correlate with the degree of renal injury, when hematuria is out of proportion to the history of trauma, it suggests preexisting renal abnormality (e.g., hydronephrosis, ectopic kidney, tumor, cystic disease, vascular malformation). Conversely, renal pedicle injuries (grade 4) may bleed little because of arterial interruption.

6. What imaging study is best to evaluate renal trauma?

Show answer
Computed tomography (CT) scan of the abdomen and pelvis with and without intravenous (IV) contrast should be performed, but it is pivotal that the perfusion and excretion phases (10 minutes after IV contrast is administered) are obtained during the study.

7. What is a single-shot IVP, and when do you perform it?

Show answer
It is an extremely abbreviated form of intravenous pyelogram (IVP) performed in emergent cases when a full evaluation is not permitted. A bolus (2 mL/kg contrast agent) is injected intravenously, and the first film should be obtained at approximately 10 minutes, with additional films at 10-minute intervals as necessary for diagnosis. Intraoperative IVP is recommended when renal damage is first suggested (e.g., retroperitoneal hematoma) during emergency surgery for other injuries.

8. How is renal trauma classified?

Show answer

* Grade 1: contusion
* Grade 2: superficial laceration
* Grade 3: deep laceration without collecting system damage
* Grade 4: contained renal pedicle injury or deep laceration and collecting system damage
* Grade 5: shattered kidney or avulsion of renal hilum

Grade 1, 2, and 3 injuries are safe to watch with nonoperative management, whereas grades 4 and 5 typically require operative intervention for repair or removal. Grade 4 injury (pedicle injury) is picked up by ipsilateral urographic nonfunction and nominal bleeding. Grade 5 injury is manifested by urographic nonfunction, parenchymal shattering, and significant gross hematuria.

9. What are the different kinds of renal pedicle trauma?

Show answer
The renal pedicle may be interrupted by thrombosis or complete avulsion; both events are characterized by urographic nonvisualization and minimal hematuria. The most common site of arterial interruption is the junction of the proximal and middle thirds of the main renal artery. Although hematuria is often absent, one may see transitory gross hematuria or microhematuria, emphasizing the requirement for urinalysis in all circumstances.

10. How long can a nonperfused kidney tolerate warm ischemia?

Show answer
Irreversible renal damage may be seen in kidneys after 30 minutes of warm ischemia, and after 8 hours of ischemia, renal salvage is minimal. Recently, single reports of renovascular trauma with intimal tear treated with endovascular stents have been encouraging.

11. What is the significance of delayed gross hematuria?

Show answer
This occurs 3-4 weeks after trauma and may indicate an arteriovenous fistula. Selective embolization is the next step if conservative therapy (bed rest) fails. Rarely, operative intervention, usually for partial nephrectomy, is necessary.

12. How do you deal with unexpected retroperitoneal bleeding noted at operation?

Show answer
A pulsatile hematoma suggests a major vascular injury, and exploration should be preceded by vascular control (both proximal and distal) and preparation for rapid blood replacement. Stable hematomas (above the pelvic brim) may be left undisturbed unless studies (preoperative or intraoperative) disclose severe renal damage. When doubt exists, exploration is justified, with the likelihood of losing a kidney.

13. How are patients with posttraumatic urine extravasation managed?

Show answer
When urine extravasation is caused by a major laceration into the collecting system and coexists with significant persistent bleeding, surgical correction is advised. Otherwise, urine extravasation commonly resolves promptly. Reimaging at 48-72 hours defines cases requiring drainage, stenting, or operative repair.

14. What is included in conservative management of renal trauma?

Show answer
Conservative management includes bed rest until gross hematuria has subsided. Strenuous activity is avoided until microhematuria has subsided (usually within 3 weeks). Patients followed for grade 5 renal trauma should undergo ultrasonography, CT scan of the abdomen and pelvis, or urography at 6 weeks. Hospitalization is not required during these periods.

15. What is the likelihood of subsequent hypertension?

Show answer
Documented posttraumatic hypertension occurs in < 2% of patients and is renin mediated. Onset generally occurs within the first several months of injury. The mechanisms of posttraumatic hypertension are renal artery stenosis or occlusion, renal parenchymal compression (extravasation of blood or urine), and posttrauma arteriovenous fistula.

16. How are most ureters damaged?

Show answer
In the civilian world, excluding iatrogenic injuries, penetrating trauma is responsible for 4% of ureteral injuries, and 1% are caused by blunt trauma.

KEY POINTS: PRINCIPLES OF URETERAL REPAIR

1. Primary tension-free anastomosis is preferred over stent with absorbable suture.
2. For a distal injury in the lower third of the ureter, perform ureteroneocystostomy; suspend the bladder if tension exists.
3. For middle third injuries, perform end-to-side transretroperitoneal ureteroureterostomy.
4. For proximal injury with significant length loss, use nephrostomy tube for drainage.

17. How do you evaluate and identify ureteral injury?

Show answer
The site and mechanism of trauma should prompt the surgeon to suspect ureteral injury. The clinical manifestations are characteristically subtle and often obscured by coexisting injury and complaints. The majority of gunshot wounds and stabbings that injure the ureter also injure bowel, colon, liver, spleen, blood vessels, or pancreas. Hematuria is often microscopic, but it may be absent. Extravasation of contrast may be detected with noninvasive (IVP and CT scan) and invasive (anterograde and retrograde ureteropyelogram) imaging studies. If ureteral injury is suspected during laparotomy, indigo carmine (1 vial IV bolus) should be given to identify the site of leakage (blue coloration).

18. What are the potential consequences of missed ureteral injury?

Show answer
Fever, leukocytosis, azotemia, flank pain, ileus, urinoma, or urinary fistula. Presentation is often delayed by several weeks after the injury.

19. What are the principles of ureteral repair?

Show answer
Devitalized tissue must be debrided, and the two ends of the ureters should be mobilized, spatulated, and anastomosed (tension free) over a ureteral stent using absorbable suture. Placement of a drain should be performed without rubbing on the fresh anastomosis. Distal injuries permit direct implantation of the ureter into the bladder. Midureteral injuries may be repaired by primary anastomosis. Pediatric patients are more susceptible to proximal complete ureteral disruption. Urgent surgical repair is mandatory. Rarely, when nephrectomy is not an option and ureteral damage prevents standard methods of reconstruction, other elective and more complex surgical reconstructive techniques may be applied. These include kidney autotransplantation, ileal interposition, transureteroureterostomy, Boari flap with nephropexis, and ureterocalicostomy.

20. The distal ureter is injured and ureteral reimplantation with a psoas hitch (tack up the bladder to the psoas muscle) is performed. Postoperatively, the patient complains of anterior thigh numbness. What did you do wrong?

Show answer
The genitofemoral nerve lies on the anterior aspect of the ileopsoas muscle. You caught this nerve when you synched this to the tendon of the psoas muscle.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
1. Armstrong PA, Litscher LJ, Key DW, McCarthy MC: Management strategies for genitourinary trauma. Hosp Phys 34:19-25, 1998.
2. Campbell EW Jr, Filderman PS, Jacobs SC: Ureteral injury due to blunt and penetrating trauma. Urology 40:216-220, 1992. Medline Similar articles Full article
3. Carroll PR, McAninch JW, Klosterman PW, et al: Renovascular trauma: Risk assessment, surgical management, and outcome. J Trauma 30:547-552, 1990. Medline Similar articles Full article
4. Kim FJ: Urologic trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma Companion Handbook, 4th ed. New York, McGraw-Hill, 2002.
5. McAninch JW: Traumatic and Reconstructive Urology. Philadelphia, W.B. Saunders, 1996.
6. McAninch JW, Santucci R: Genitourinary trauma. In Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 3707-3744.
7. Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J Trauma 29:1664-1666, 1998.
8. Peterson NE: Genitourinary trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma, 4th edition. Norwalk, CT, Appleton & Lange, 1996, pp 661-694.
9. Skinner EC, Parisky YR, Skinner DG: Management of complex urologic injuries. Surg Clin North Am 76:861-878, 1996. Medline Similar articles

1. How common are pancreatic injuries?

Show answer
The pancreas is not commonly injured because of its protected retroperitoneal position, and thus accounts for only 8% of all penetrating and 2% of all blunt visceral injuries.

2. What other injuries are typically associated with penetrating pancreatic trauma?

Show answer
Liver injury is the most frequent concomitant injury, with a reported incidence of ≤ 50%. Other commonly associated injuries include the stomach (40%), large abdominal vessels such as the aorta and vena cava (40%), spleen (25%), kidneys (2%), and duodenum (20%).

3. How are pancreatic injuries diagnosed and staged preoperatively?

Show answer
Preoperatively, computed tomography with intravenous contrast enhancement may actually demonstrate a transected pancreas or major destruction of portions of the gland and has a high positive predictive value; however, it suffers from a low negative predictive value (i.e., it may miss even big injuries). Ultrasound does not consistently image the retroperitoneum adequately and is often hampered by overlying bowel gas. Elevated serum amylase concentrations are nonspecific for pancreatic injury and can be normal in a high proportion of patients shown subsequently to harbor significant injuries to the gland. Diagnostic peritoneal lavage is also unreliable. Short of mandatory exploration, there are no universally reliable methods to assure early diagnosis of significant pancreatic injuries. Surgeons must pay particular attention to the mechanism of injury and subtle signs and symptoms of the physical examination and combine them with data obtained from imaging studies.

4. What are some of the commonly used surgical options for the treatment of pancreatic injuries?

Show answer
Most low-grade penetrating and blunt injuries to the pancreas are adequately treated by closed suction drains placed at surgery. First, the integrity of the main pancreatic duct should be evaluated, either by direct inspection or by intraoperative pancreatography. Distal duct injuries (defined as those occurring to the left of the superior mesenteric vessels) are treated with distal pancreatectomy, with or without splenectomy, and closed drainage of the pancreatic stump. Preservation of the spleen is preferable. Injuries to the proximal portion of the gland that do not involve the main duct are treated with closed suction drainage. Injury to the pancreatic duct in the head or neck of the pancreas may require resection of significant portions of distal pancreas. If more than 80% of the gland is removed, the risk of endocrine and exocrine pancreatic insufficiency is high. Try to preserve distal glandular tissue by incorporating it into a Roux-en-Y pancreaticojejunostomy. With severe pancreatic head destruction, instances involving significant injuries to the duodenum and distal biliary structures may require a pancreaticoduodenectomy (i.e., Whipple procedure). Recent reports of successful nonoperative management of complete pancreatic transections in pediatric patients may shift the approach to these injuries away from resection, although the current standard of care remains surgical.

KEY POINTS: SURGICAL OPTIONS FOR PANCREATIC INJURIES

1. Low-grade injuries are treated with simple closed suction drainage at the time of celiotomy.
2. In unstable patients, debride, obtain hemostasis, and drain. Deal with the resultant fistula at a later time.
3. If ductal injury is suspected in a stable patient, visualize with ERCP or cholangiogram.
4. If ductal injury is present in the head or neck of the pancreas, ligate proximally and attempt to preserve pancreatic tissue with Roux-en-Y pancreaticojejunostomy.
5. Always place a jejunal feeding tube.

5. Is an elevated serum amylase level diagnostic of pancreatic trauma?

Show answer
No. Up to 40% of patients who have sustained significant pancreatic injury do not show elevations in their initial serum amylase level. There appears to be a slightly higher positive predictive value if the elevated amylase level is obtained more than 3 hours after the patient’s injury, although elevated amylase is common with trauma not involving the pancreas. Up to 40% of patients sustaining isolated head trauma can present with serum hyperamylasemia, which is unrelated to pancreatic injury.

6. How do blunt pancreatic injuries differ in children and adults?

Show answer
Adult pancreatic injury is usually either penetrating (e.g., stab and gunshot wounds) or high-speed blunt forces (e.g., motor vehicular crashes). Children usually present after direct blows to the epigastrium, typically from bicycle handlebars, which compress the pancreas between the anterior surface of the thoracic spine and the handlebar, often resulting in complete glandular transection.

7. What is the optimal route of nutritional supplementation after a major pancreatic injury?

Show answer
Direct feeding into the stomach is contraindicated because it stimulates pancreatic exocrine secretion and aggravates healing, potentiating secondary pancreatitis and pancreatic fistulas formation. Postpyloric enteral nutrition can be delivered safely and effectively via a feeding jejunostomy tube placed at the completion of the abdominal exploration and pancreatic repair.

8. Describe the common complications of pancreatic injuries.

Show answer
Complications are common. The two most common are pancreatic fistulas and intraabdominal abscesses. Other problems are pancreatitis, pancreatic pseudocyst, and pancreatic hemorrhage. Most patients who die after sustaining injuries to the pancreas do so as a result of late complications and not from the pancreatic injury itself.

9. What is the role of computed tomography (CT) scanning in diagnosing blunt duodenal injuries?

Show answer
Although CT is an excellent tool for visualizing solid organ injuries, CT is less useful with injuries to hollow organs such as the duodenum. Even the addition of an oral contrast agent to the study does not seem to improve the diagnostic yield. Subtle signs of duodenal injury on CT scans include periduodenal edema or fluid and retroduodenal air, which usually indicates a duodenal rupture and spillage of small amounts of intralumenal contents into the retroperitoneum.

10. What is the importance of the Kocher maneuver?

Show answer

In 1903, Kocher described what has now become a routine maneuver during the exploratory celiotomy to visualize and repair injuries to the duodenum, distal common bile duct, and pancreatic head. The avascular lateral peritoneal attachments to the duodenum are incised sharply; then the duodenal sweep is elevated and reflected medially, allowing for inspection and palpation of its posterior surface as well as of the head of the pancreas.

11. What are the four portions of the duodenum and their surgical relationships?

Show answer
The first portion of the duodenum starts at the pylorus (intraperitoneally) and passes backward (retroperitoneally) toward the gallbladder (the remainder of the duodenum is retroperitoneal). The second portion descends 7-8 cm and is anterior to the vena cava. The left border of the duodenum is attached to the head of the pancreas, at the site where the common bile and pancreatic ducts enter; it shares a common blood supply with the head of the pancreas through the pancreaticoduodenal arcades. The third portion of the duodenum turns horizontally to the left, with its cranial surface in contact with the uncinate process of the pancreas, and passes posterior to the superior mesenteric artery and vein. The fourth portion continues to the left, ascending slightly and crossing the spine anterior to the aorta, where it is fixed to the suspensory ligament of Treitz at the duodenojejunal flexure.

12. How are duodenal injuries classified?

Show answer
An organ injury scale has been adopted that allows for standardized descriptions of duodenal injuries, which extend from grade I (least severe) to grade V (most severe). The grading of duodenal injuries assists surgeons in selecting the appropriate surgical procedure for the repair or reconstruction of these frequently complex injuries. (See Table 27-1).
Table 27-1. GRADES OF PANCREATIC INJURY

D1, D2, D3, and D4 refer to the portions of the duodenum (i.e., first through fourth).

13. What are the main surgical options for penetrating duodenal injuries?

Show answer
Most simple lacerations can be repaired primarily. Complex lacerations with devitalized margins or lacerations that involve > 50% of the duodenal circumference require debridement of margins and re-anastomosis of the divided ends. If tension on the suture line is anticipated because of extensive tissue loss, adjunctive techniques such as Roux-en-Y duodenojejunostomy or pyloric exclusion are more appropriate. Protection of a duodenal repair is best assured by a tube duodenostomy and generous external drainage. With severe duodenal injury that involves distal biliary structures and the pancreatic head, a pancreaticoduodenectomy (i.e., Whipple procedure) may be the most appropriate option.

References
WEB SITE
http://www.acs.surgery.com/abstracts/acs/acs0507.htm

BIBLIOGRAPHY
1. Asensio JA, Demetriades D, Hanpeter DE, et al: Management of pancreatic injuries. Curr Probl Surg 36:325-419, 1999. Medline Similar articles
2. Ilahi O, Bochicchio GV, Scalea TM: Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: A single-institutional study. Am Surg 68:704-707, 2002. Medline Similar articles
3. Ivatury RR, Nallathambi M, Gaudino J, et al: Penetrating duodenal injuries. Analysis of 100 consecutive cases. Ann Surg 202:153-158, 1985.
4. Jobst MA, Canty TG Sr, Lynch FP: Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg 34:818-823, 1999. Medline Similar articles Full article
5. Moore EE, Cogbill T, Malangoni M, et al: Organ injury scaling II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 30:1427, 1990. Medline Similar articles
6. Patel SV, Spencer JA, el-Hansani S, Sheridan MB: Imaging of pancreatic trauma. Br J Radiol 71:985-990, 1998. Medline Similar articles
7. Patton J, Lyden S, Croce M, et al: Pancreatic trauma: a simplified management guideline. J Trauma 43:234-239, 1997.
8. Takishima T, Sugimoto K, Hirata M, et al: Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: Its significance and limitations. Ann Surg 226:70-76, 1997. Similar articles Full article
9. Vasquez JC, Coimbra R, Hoyt DB, et al: Management of penetrating pancreatic trauma: An 11-year experience of a level-1 trauma center. Injury 32:753-759, 2001. Full article
10. Wales PW, Shuckett B, Kim PC: Long-term outcome after nonoperative management of complete traumatic pancreatic transaction in children. J Pediatr Surg 36:823-827, 2001. 1. Young PR Jr, Meredith JW, Baker CC, et al: Pancreatic injuries resulting from penetrating trauma: A multi-institution review. Am Surg 64:838-843, 1998. Medline Similar articles