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2. Ultrasonography.
3. CT scan.
4. ERCP
Management:
1. A partial avulsion of the body and tail or complete transection are
treated by excision, pancreatic duct should be identified and ligated
with a non absorbable suture and a drain is led down to the site.
2. If the tear isn’t so severely lacerated and distal, it is indicated to
amputate the distal gland even if the duct is intact.
3. If the duct is transected in the base of the laceration, it will leak
whatever sutures are inserted,there are 2 possibilities:
a. Drain the site with a soft tube drain stitched to the adjacent
pancreatic capsule.
b. Apply a jejunal loop to the defect in the expectation of a fistula.
4. Pancreatic duodenectomy (whipple procedure) used in massive
injury.
**Post-operative management:
1. Antitrypsin substance eg: Aprotinin for up to 5 days, can inhibit
the development of pancreatitis.
2. Protect the skin around the drain by barrier cream.
**Possible complications after surgery of pancreas:
A. Pancreatic fistula.
B. Pancreatitis.
C. Pancreatic pseudocyst. This is treated when indicated by cysto-
gastrostomy or into roux loop of jejunum.
150
Kidney Injury
Kidney injury is common trauma falls and automobile accidents. It is
commonly suspected if fractures of the 11th-12th ribs or flank
tenderness is found. If hematuria (to any degree) is present, the nature
of the injury must be determined. Kidney lacerations can bleed
extensively into the retroperitoneal space.
Clinical Findings: The ruptured kidney usually presents with pain on
inspiration in the abdomen and flank, and CVA tenderness. Gross
hematuria will almost invariably be present, but the injury can still
occur with only microscopic hematuria.
Flank discoloration is a late finding that will never be present in the
emergency department. The contused kidney can present with identical
findings.
Diagnosis:
Differentiating between the lacerated kidney and the contused kidney
requires IVP examination or CT scan. If a contrast study such as an
aortogram is required for another reason, the kidneys can be assessed
during the course of that study.
The lacerated kidney will show leakage of dye, whereas the contused
kidney will either be normal or show a “blush” of dye in the kidney
stroma. A non-visualizing kidney implies severe rupture or avulsion of
the renal pedicle.
Treatment:
The contused kidney is simply observed. Some kidney lacerations can
be managed non-operatively. Surgical management is mandatory for
any kidney that shows extravasation of dye.
151
Bowel Rupture
The most common injuries of intestine that break the wall of the
bowel are penetrating injuries. In penetrating trauma, the small bowel
is most frequently injured, followed by the stomach and large intestine.
Rupture of bowel also can occur when a localized crush happens,
such as when the steering wheel pinches the duodenum against the
spine. In blunt trauma, most commonly the duodenum is injured,
because of its location and its ligamentous attachments.
Clinical Findings: Symptoms are caused by the intestinal contents,
rather than blood loss. Stomach rupture causes rapid onset of burning
epigastric pain, followed quickly by rigidity and rebound sensitivity.
Small bowel and colon injury may present only with vague
generalized pain, with peritonitis following after hours. Duodenal
injury may cause back pain.
This small, almost invisible colon injury, can cause fatal peritonitis if
not recognized and treated
152
Diagnosis:
The diagnosis of bowel rupture is made by finding free air on abdominal
x-ray. Use a decubitus or cross-table view for the patient who cannot
stand for an upright view. Duodenal or sigmoid colon injury may result
in retroperitoneal air only. Peritoneal lavage will show WBCs and
intestinal content, except for retroperitoneal duodenal or sigmoid rupture.
Contrast examination may be required in equivocal cases, if surgery is
not indicated for another reason.
Treatment:
Surgical repair is required. In cases of small bowel rupture commonly
over suture of the small lesion is enough, in extended cases resection
is needed. Large bowel rupture is usually treated with suturing and
sometimes protective colostomy is indicated.
153
Trauma In Pregnancy
Trauma in pregnancy is the commonest cause of non-obstetric maternal
death. When dealing with pregnant injured patient, it is essential to
take in consideration that two lives are at risk.
The pregnant patient who sustains trauma is usually extremely
anxious about herself and her baby. The fetus may die unless the
mother is adequately resuscitated. Management and treatment priorities
are the same as for the non-pregnant patient, but during resuscitation
and stabilization one should take account of the anatomical and
physiological changes of pregnancy. Early consultation and involvement
of an obstetrician is usually needed.
CAUSES OF TRAMA IN PREGNANCY.
Road traffic accidents are the commonest reason for hospital admission
following trauma in pregnancy. Other causes include blunt trauma as
a result of assault or falls, penetrating trauma due to stabbing or gunshot
wound, and burns.
The use of seat belts by pregnant women should reduce both maternal
and fetal mortality by preventing ejection from the vehicle.
THE EFFECTS OF ANATOMICAL CHANGES OF PREGNANCY ON
THE RESPONSE TO TRAUMA.
The anatomical changes of pregnancy make the uterus and its contents
155
more susceptible to penetration, uterine rupture, placental abruption
and rupture of the membranes.
During the first trimester the fetus lies within the thick-walled uterus
and is protected against injury by the bony pelvis. After the 12th week
of gestation the uterus becomes an intra-abdominal organ and
therefore more vulnerable to direct injury. During the second trimester
the fetus is cushioned by a large volume of amniotic fluid. But by the
end of the third trimester the uterus is thin-walled and offering little
protection to the fetus. The continuous enlargement of the uterus
during pregnancy displaces the intestines to the upper abdomen.
Because of the difference in elasticity between the uterine wall and the
placenta, a placental abruption may result after abdominal trauma.
Myometrial injury can cause uterine contractions.
THE EFFECTS OF PHYSIOLOGICAL CHANGES OF PREGNANCY ON
THE RESPONSE OF TRAUMA.
The respiratory rate in pregnancy is usually unchanged, but tidal volume
increases and residual capacity falls. This causes a physiological
hyperventilation during pregnancy. A pregnant trauma patient could
have both maternal and fetal acidosis. The cardiac output increases
during pregnancy. In the supine position the pressure of the uterus on
the great vessels may cause aorto-caval compression and leads to a
decrease of the cardiac output. The resting pulse rate increases by 1520 beats \ min. in the third trimester.
The systolic and diastolic blood pressure fall by 15 mmHg in the second
trimester, returning to normal by term. Blood volume increases by 50
% at 34 weeks of gestation.
Fractures of the pelvis are often associated with massive haemorrhage
156
from dilated pelvic veins. Any damage to the placental bed may cause
severe haemorrhage due to its high vascularity. Because of the increased
circulating blood volume the pregnant patient could lose 50% more
blood than a non-pregnant patient before signs of hypotension or
shock could occur. Vasoconstriction of the placental vessels due to
catecholamines could preserve the maternal circulation at the expense
of fetal perfusion.
The fetus may therefore be shocked before signs of maternal shock
develop. Sometimes supine position of the pregnant patient may
cause hypotension or signs of shock that can be corrected by bringing
the pregnant patient in normal position.
The enlarged uterus is causing a displacement of the gastro-intestinal
tract to the upper abdomen which increases the risk of aspiration of
gastric contents into the lungs because of an increase of intragastric
pressure.
Stretching of the peritoneum and abdominal musculature by the
gravid uterus diminishes rebound tenderness and guarding as signs of
abdominal injury.
The renal plasma blood flow and the glomerular filtration rate increase
during pregnancy and glucosuria is common in pregnant women.
The bladder is displaced upwards and anteriorly by the enlarging uterus
after the 12th week and more susceptible to direct injury. The mass of
the pituitary gland increases by up to 50% during pregnancy.
Eclampsia is a complication of pregnancy which could mimic head
injury.
If a pregnant patient has convulsions with the presence of oedema and
proteinuria, eclampsia must be considered.
157
During pregnancy the white blood cell count is increased and a slight
dilutional anemia could occur, because of a smaller increase in red
cell mass than circulatory volume.
Fetal Physiology
The effect of trauma on pregnancy depends on the gestational age of
the fetus, the type and severity of the trauma, and the extent of
disruption of normal uterine and fetal physiology. The survival of the
fetus depends on adequate uterine perfusion and delivery of oxygen.
The uterine circulation has no autoregulation which implies that
uterine blood flow is related directly to maternal systemic blood
pressure, at least until the mother approaches hypovolemic shock. At
that point, peripheral vasoconstriction will further compromise uterine
perfusion. Once obvious shock develops in the mother, the chances of
saving the fetus are about 20 %.
If fetal oxygenation or perfusion are compromised by trauma, the
response of the fetus may include bradycardia or tachycardia, a
decrease in the baseline variability of the heart rate, the absence of
normal accelerations in the heart rate, or recurrent decelerations. It
should be noted that an abnormal fetal heart rate may be the first
indication of an important disruption in fetal homeostasis. During
trauma resuscitation, evaluation of the fetus should begin with
auscultation of heart tones and continuous recording of the heart rate.
Trauma to the uterus (direct or indirect) can also injure the myometrium
and destabilize decidual lysosomes, releasing arachidonic acid that
can cause uterine contractions, and perhaps inducing premature labor.
Maternal Physiology
Increases in cardiac output and blood volume begin early in the first
trimester and are 30-40% above the nonpregnant state by 28 weeks.
158
This relative hypervolemic state and hemodilution is protective for
the mother because fewer red blood cells are lost during hemorrhage.
The hypervolemia prepares the mother for the blood loss that
accompanies vaginal delivery (500 ml) or cesarean section (1000 ml).
However, almost 40% of maternal blood volume may be lost prior to
the manifestation of signs of maternal shock.
Despite the increase in blood volume and cardiac output, the
parturient is susceptible to hypotension from aortocaval compression
in the supine position. Only about 10% of pregnant patients at term
develop symptoms of shock in the supine position, but fetal compromise
can be occurring even in the asymptomatic mother. Left uterine
displacement increases cardiac output by 30% and restore circulation.
Uterine displacement must be maintained at all times during
resuscitation, transport and perioperatively for nonobstetrical surgery.
As the uterus enlarges, the diaphragm rises about 4 cm and the diameter
of the chest enlarges by 2 cm, increasing the substernal angle by 50%.
Care should be taken to consider these anatomic changes when
thoracic procedures such as thoracostomies are being performed. The
most important respiratory change during pregnancy is the decrease
in functional residual capacity (FRC). Beginning in the second
trimester, there is a 20% decrease in FRC coupled with a 20%
increase in oxygen consumption. In addition, 30% of parturients have
airway closure during normal tidal ventilation in the supine position.
All these changes predispose to rapid falls in PaO2 during periods of
apnea or airway obstruction. Hence, supplemental oxygen is always
indicated for these patients in the resuscitation room. Minute
ventilation increases at term by 50% due to an increase in tidal volume,
so normal PaCO2 falls to 30-32 mmHg with a slight compensatory
decrease in plasma bicarbonate levels.
159