Linkman 2015 - Paediatric Abdo Trauma

Acute Paediatric Surgical Abdomen or Trauma in the DGH:
Operate or Transfer?
• Mark Powis
• Consultant Paediatric Surgeon
• Leeds Teaching Hospitals
Abdominal Trauma in Children
• Trauma is the major cause of mortality in infancy
and childhood
• Blunt injury predominates, often multisystem
• Organs injured:
– Spleen
– Liver
– Kidneys
Abdominal Trauma in Children
• Anatomical differences:
– Ribcage small and compliant
– Abdomen begins at level of nipples
– Upper abdominal organs larger
– Abdominal musculature less developed
• Physiological differences
• Psychological differences
Mechanisms of Injury
Number of Patients
50
Blows
Crush
Fall <2m
Fall >2m Other
Other
Shooting
RTC
40
30
20
10
0
Mechanism of Injury
Splenic Trauma
• Commonest solid organ
injured
• Management operative up
to 1980s
– But OPSI had 50% fatality
•
Toronto 1956-2006
– Non-op 42%→ 97%
– Salvage rate 42% → 99%
• Yorkshire 1994-1999
– 11 splenectomies
– None met indications
Classification of Injury
American Association for the Surgery of Trauma Committee on Organ Injury
Scaling
Liver Trauma
• Largest organ in
abdomen
• 2nd commonest solid
organ damaged
• Mortality and
morbidity correlate
with associated
injuries not degree of
hepatic damage
Classification of Injury
American Association for the Surgery of Trauma Committee on Organ Injury
Scaling
Renal Trauma
• Third most common
solid organ injured
• Conservative
management
– Retroperitoneal
haematoma
• Operative management
– Pedicle injury
– 20 mins warm ischaemia
Visceral Injury
• Rarely in isolation
• Handle-bar injury
• Seat belt complex
– Both associated with
pancreatic trauma
• Free intraperitoneal or
retroperitoneal air on
imaging
• Often appreciated late
• Operative repair +
diversion/ostomy
Visceral Injury- Imaging
• CT scan
• Plain abdo films
+ Lat/Decubitus)
(AP
Injury Severity Score (ISS)
ISS = sum of square of three
highest AISs
Max 75
Any AIS 6 ISS=75
ISS>15 major trauma
AIS Score
Injury
1
Minor
2
Moderate
3
Serious
4
Severe
5
Critical
6
Unsurvivable
Region
Injury
Description
AIS
Square
Top Three
Head & Neck
Cerebral Contusion
3
9
Face
No Injury
0
Chest
Flail Chest
4
16
Abdomen
Minor Contusion of Liver
Complex Rupture Spleen
2
5
25
Extremity
Fractured femur
3
External
No Injury
0
Injury Severity Score:
50
TU Bypass
Paediatric Trauma
Abdominal Trauma in Children Approach
• Approach should be based on APLS / ATLS
guidelines
– Primary survey: A + Cx spine;B; C; D; E
– Resuscitation
– Secondary survey
– Emergency treatment
– Definitive care
Management
Blunt trauma
Penetrating trauma
All trauma
Conservative
• 70%
Operative
• 50-60%
Conservative
• If haemodynamically
stable
• If haemodynamically
unstable: 72% mortality
Non-Operative Management
• Haemodynamic stability
after < 40% BV crystaloid
• Documentation of injury
with CT
• Active observation on
HDU/ITU
• Laparotomy if become
unstable
Guidelines in Isolated Splenic and Liver Injury
(Stylianos + APSA Trauma Committee, J Pediatr Surg 35:164-169, 2000)
CT Grade
I
II
III
IV
ICU stay
None
None
None
1
2
3
4
5
Predischarge imaging
None
None
None
None
Postdischarge imaging
None
None
None
None
3
4
5
6
Hospital days
Activity restriction (wks)
• Risk of splenectomy
Operative Intervention
• Resuscitation laparotomy
– Exsanguinating pt, no response to fluid, abdo trauma
+ no other obvious cause
• Emergency laparotomy
– Diaphragmatic rupture, protrusion of viscus, GI
bleeding, gunshot wound
• Ix + laparotomy
• Conservative + laparotomy
• No abdominal injuries requiring lap
Operative Approaches
• Extensive laparotomy sorting out all problems at
the time
• Limited surgery, life preserving procedures to
gain time and stability
• Latter concept: DAMAGE CONTROL
• Damage control only needed in 10-20% of
operative cases
Damage Control
H
E
haemorrhage control
eliminate contamination and expect other
injuries
L
limit surgery
P
precision repairs
• Limit time < 60 mins
• Watch for:
– Hypothermia; Acidosis; Coagulopathy
Damage Control Laparotomy
PICU: rewarm, correct coagulopathy,
max haemodynamics, ventilatory
support, identify injuries
Theatre: pack removal,
definitive repair
Trauma in DGH
OPERATE OR TRANSFER?
Why Operate in DGH?
Resuscitation Laparotomy
• Acutely unstable child
following blunt trauma
– presents to DGH
– Transferred to DGH as no MTC
within 45 mins
– Actively bleeding
– Damage Control
– Secondary transfer to MTC
Planned Laparotomy
• Stable child following blunt
trauma
– Hollow viscus injury
– May be a few days down the
line
– May need PICU / TPN after
– Secondary transfer to MTC
– ? Transfer pre-surgery
Active Splenic Bleeding
• Splenectomy
• Splenorrhapy
• Splenic Conservation
– Haemostatics
• Floseal, Coseal, Surgicel
– Pressure
• Embolisation if can be
stabilised
Active Hepatic Bleeding
•
•
•
•
•
•
•
Pack the liver
Pringle manoeuvre
Liver sutres
Aortic cross clamping
Hepatic artery ligation
Liver clamping
Total vascular
exclusion
Renal Trauma
• Renal pedicle injury
– 20 mins warm
ischaemia time
• Active parenchymal
bleeding
– Nephrectomy
– Conservation
– Embolisation if stable
Visceral Injury
• Visceral perforation
– Excision and primary
repair
– Toilet and exclusion
– Stoma formation
– Central line and TPN
Trauma in the DGH: Conclusions
• Operative intervention in DGH inevitable
– BUT should only be life saving
– Surgeons + Anaesthetists need appropriate
skills
• Education to avoid unnecessary or excessive
operations
• Transfer to MTC
– Pre-operatively, if stable, preferable
– Post-operatively