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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1566_Библиотеки_им_академика_М_И_Перельмана
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Abdominal Trauma - New Solutions to Old Problems
50
Figure 2.
Evaluation of erythrocytosis.
Other common hematological disorders needing attention:- sickle cell anemia,
leukcopenia, nutritional deficiencies, bone marrow suppression, thalassemia, chronic
renal failure, hemolytic anemias etc.
6.2 Steps of homeostasis
Injury to vessel wall ➔ primary vasoconstriction ➔ interaction of von
Willebrand protein with sub endothelium ➔ formation of platelet plug ➔ fibrin
formation ➔ clot dissolution and endothelial regeneration (Figure 3).
Assessment of homeostasis: careful history, bleeding time, prothrombin time, APTT,
PT-INR, platelet count (Table 3).
Differential diagnosis for deranged coagulation test
• Prolonged bleeding time: Thrombocytopenia, von Willebrand disease, platelet
function defect,
• Prolonged PT: liver disease, vitamin K deficiency, factor VII deficiency, warfarin
use
• Prolonged PTT: Factor XII, XI, IX, or VIII deficiency, von Willebrand disease,
heparin induced, DIC.
• Prolonged PT and PTT: Vitamin K deficiency, DIC, warfarin induced.
After diagnosis of bleeding disorder the treatment should be initiated accordingly
with platelet or fresh frozen plasma infusions, corticosteroids, anti D etc [8].
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Threatening but Preventable and Treatable Medical Complications of Abdominal Trauma
DOI: http://dx.doi.org/10.5772//106134
Figure 3.
Coagulation scheme with anticoagulant mechanisms. FSP:- fibrin split products; PT:-prothrombin time; PTT:partial thromboplastin time; tPA:- tissue plasminogen activator.
Significant findingsPathophysiology Causes
Production
decreased
Destruction
increased
Table 3.
Causes of thrombocytopenia: which needed to be treated according to cause after abdominal trauma for optimal
homeostasis.
Idiopathic
thrombocytopenic
purpura, acquired
immunodeficiency
syndrome, drug
induced, systemic
lupus erythematosus
leukopenia, anemia, abnormal bone marrow, Folate deficiencyAplastic anemia
abnormal, vitamin B12 low, radiotherapy or chemotherapy
Splenomegaly, hypercellular bone marrow, anemia,hypersplenisimSequestration
leukopenia, normal smear
Hematocrit,white blood cell count are usually normal with
normal smear, megakaryocytic hyperplasia
7. Assessment of respiratory pathologies
See Figures 4 and 5.
7.1 Risk factors for post traumatic pulmonary complications
See Table 4.
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Abdominal Trauma - New Solutions to Old Problems
52
Figure 4.
Pathophysiology of the events leading to postoperative pulmonary complications. V/Q , ventilation/perfusion.
Figure 5.
Pathogenesis of major post traumatic pulmonary complications.
7.2 Causes of post traumatic pleural effusions
A) Transudate:-
• Congestive heart failure
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Threatening but Preventable and Treatable Medical Complications of Abdominal Trauma
DOI: http://dx.doi.org/10.5772//106134
Procedure-relatedPatient-related
• General health and nutritional status
Age
Low albumin
• >Functional status
Weight loss >10%
ASA Class
Goldman class
• Respiratory status
COPD history
Tobacco use
Sputum production
Pneumonia
Dyspnea
OSA
• Neurological status
Impaired sensorium
• CVA history
• Fluid status
• CHF history
• Renal failure
Low or high BUN
• Preoperative blood transfusion
• Immune status
• Chronic steroid use
• Alcohol use
• Incision near diaphragm
Thoracic surgery
Upper abdominal surgery
AAA repair
• Surgery technique
Open vs. laparoscopic
• Anesthesia duration >2h
• Use of spinal/epidural anesthesia vs. general anesthesia
• Use of long-acting neuromuscular blockade (pancuronium)
• Pain control with parenteral narcotics vs. epidural analgesia
• Postoperative Nasogastric tube placement
Table 4.
Risk factors for post traumatic pulmonary complication.
• Hypervolemia
• Ascites
• Misplaced central venous catheter
• Pulmonary embolism (rarely)
• Postpericardiotomy syndrome
• Diaphragmatic contusion
B) Exudate:-
• Pneumonia
• Pulmonary embolism
• Subphrenic abscess
• Empyema
• Atelectasis
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Abdominal Trauma - New Solutions to Old Problems
541555
8. Assessment of cardiovascular diseaes
8.1 Clinical predictors of increased perioperative cardiovascular risk (myocardial
infarction, congestive heart failure, death)
• Major [9]
◦ Unstable coronary syndromes
◦ Acute MI (documented MI less than 7 days previously)
◦ Recent (greater than 7 days but less than or equal to 30 days).
◦ Significant arrhythmias
◦ myocardial infarction with evidence of important ischemic risk by clinical
symptoms or non-invasive study
◦ Severe valvular disease
◦ Unstable or severe angina (Canadian class III or IV)
◦ High grade atrioventricular block
◦ Symptomatic ventricular arrhythmias in the presence of underlying heart
disease
◦ Decompensated congestive heart failure
◦ Supraventricular arrhythmias with uncontrolled ventricular rate
• Intermediate
◦ Previous myocardial infarction by history or pathologic Q waves
◦ Mild angina pectoris (Canadian class I or II)
◦ congestive heart failure
◦ Renal insufficiency (serum Cr > 2.0 mg/dl)
◦ Diabetes mellitus
• Minor
◦ Abnormal electrocardiogram (left ventricular hypertrophy, left bundle
branch block, ST–T abnormalities)
◦ Low functional capacity like inability to climb one flight of stairs
◦ Rhythm other than sinus (e.g., atrial fibrillation)
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Abdominal Trauma - New Solutions to Old Problems
56
Nutritional disorders (starvation, liquid protein diets), Subarachnoid
hemorrhage, Intracerebral hemorrhage, Head trauma, Encephalitis.
8.3 Indications for implantation of cardiac pacemakers
• Third-degree or advanced second-degree AV block associated with symptomatic
bradycardia [10]
• Second-degree AV block with symptomatic bradycardia, bifascicular block with
intermittent complete heart block with symptomatic bradycardia or symptomatic
bifascicular block with intermittent type II block
• Second-degree AV block with sinus node dysfunction and symptomatic
bradycardia
• After acute myocardial infarction with persistent second-degree AV block,
bilateral bundle–branch block or third-degree AV block.
• Symptomatic and persistent second- or third-degree AV block.
8.4 Endocarditis prophylactic regimens for gastrointestinal injury surgery in
abdominal trauma patient
Bacterial endocarditis prophylaxis is indicated for patients with specific cardiac
structural abnormalities who are at risk for bacteremia resulting from the disruption
of mucosal surfaces colonized with bacteria [11] (Table 5).
9. Assessment of gastrontestinal diseases
9.1 Factors that contribute to prolonged postoperative ileus
• Underlying medical conditions
◦ Sepsis
◦ Collagen vascular diseases
◦ Amyloidosis
◦ Diabetes mellitus
◦ Thyroid disease
◦ Peritonitis
◦ Ischemic bowel disease
◦ Electrolyte disturbances (e.g., hypokalemia)
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Threatening but Preventable and Treatable Medical Complications of Abdominal Trauma
DOI: http://dx.doi.org/10.5772//106134
RegimenAgentSituation
High-risk patients with
allergy to penicillin group
Moderate-risk with allergy
to penicillin group
Ampicillin andHigh-risk patients
gentamicin
Vancomycin
and gentamicin
Amoxicillin/Moderate risk patient
ampicillin
Adults: ampicillin 2gms intravenous or intramuscular and
gentamicin 1.5 mg/kg
(maximum dose 120 mg) 1st dose administered within 30
mints of initiation of
Procedure followed 6 h later, ampicillin 1 g intravenous or
intramuscular or oral amoxicillin
1 gms.
Children: ampicillin 50 mg/kg intravenous or
intramuscular (maximum dose 2gms)
and gentamicin 1.5 mg/kg, 1st dose administered within 30
mints of initiation of
procedure followed 6 h later with ampicillin 25 mg/kg
intramuscular r intravenous or oral
amoxicillin 25 mg/kg
Adults: vancomycin 1gm intravenous over 1–2 h with
gentamicin
1.5 mg/kg, intravenous or intramuscular (maximum dose
120 mg),
injection/infusion completed within 30 min of initiation of
surgery
Children: vancomycin 20 mg/kg, intravenous over 1–2hwith
gentamicin 1.5 mg/kg, intravenous or intramuscular, injection/
infusion completed within 30 min of initiation of surgery
Adults: Oral amoxicillin 2gms, 1 h before sugery, or
ampicillin 2gms intravenous or intramuscular, to be given
with 30 min of initiation of surgery
Children: Oral amoxicillin 50mg/kg,given 1 h before surgery,
or ampicillin 50 mg/kg intravenous or intramuscular, within
30minofinitiationofsurgery
Adults: vancomycin 1gm, intravenous, infused over 1vancomycin –2h,
within 30 min of surgery initiation
Children: vancomycin 20 mg/kg, intravenous, infusion
completed over 1–2 h of 30 min of surgery initiation.
Table 5.
Antibiotic prophylaxis for prevention of bacterial endocarditis in trauma patients.
• Intraoperative bowel manipulation
◦ Open surgical procedure
◦ Type of anesthesia
• Drugs
◦ Opiates (e.g., morphine, codeine)
◦ Opioids (e.g., fentanyl, pethidine, tramadol)
◦ Nonsteroidal anti-inflammatory drugs (e.g., diclofenac, naproxen)
◦ Phenytoin
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Abdominal Trauma - New Solutions to Old Problems
58
◦ Anticholinergic agents (e.g., trihexyphenidyl, benztropine, amantadine)
9.2 Factors that contribute to colonic PSEUDO-obstruction
• Age
• Alcoholism
• Drugs
◦ Narcotics
◦ Antidepressants
◦ Anticholinergics
◦ Clonidine
◦ Phenothiazines
• Metabolic causes
• Electrolyte imbalance
• Acid–base disturbances
• Hypothyroidism
• Diabetes mellitus
• Uremia
• Sepsis
• Inflammatory processes (e.g., pancreatitis and cholecy stitis)
• Infection
• Respiratory failure
9.3 Factors contributing to post- trauma nausea, vomiting
• Length of anesthesia
• Type of trauma (abdominal, gynecologic, urologic etc)
• Female
• Drugs
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Ulcer recurrenceWound infection
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Recurrent bleeding from ulcerAnastomotic leak
Gastric outlet obstructionBile duct injury
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