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S. Kumar et al.

 

 

In case the abdominal closure seems to be difficult during the primary surgery (due to bowel edema/retroperitoneal collection, etc.), it is prudent to leave it open as forceful closure would lead to increase in intra-abdominal pressure resulting in the abdominal compartment syndrome.

Oral diet is started at the earliest and gradually advanced to regular diet as tolerated. Immediate enteral feeding is beneficial (in comparison to parenteral) in a critically ill patient regardless of the patient’s premorbid nutritional status.

Care of the feeding jejunostomy tube should be taken properly. Postoperatively, tube feed at the rate of 30 mL/h for 3–6 h should be given. If the patient tolerates, gradually increase feed as tolerated to meet calories and protein requirement over 24–48 h.

Conditions suggesting the need for parenteral nutrition are as follows:

Oral intake less than 50% of the energy needs

Unable to tolerate nasogastric or nasojejunal feed for more than 7 days in previously well-nourished patient.

Nonfunctioning gastrointestinal tract

Inspection of the surgical sites is done for signs of inflammation and infection.

Monitoring of the drain output and nature of fluid should be done.

In case the drains show persistent and or purulent output, it can be indicative of deep surgical site infections or intestinal fistulae. If such is the case, rapid clinical/radiological examination followed by opening of laparotomy incision site and thorough lavage is indicated. If intestinal fistulae are present, it should be treated either surgically or nonoperatively depending on its location and output.

Persistent high drain output in cases of pancreatic and splenic injury should raise suspicion of the pancreatic fistula.

Drain amylase should be requested on or after the third postoperative day in cases of suspected pancreatic fistula in cases of pancreatic and splenic injury. Drain amylase three times that of serum amylase confirms pancreatic fistula. Continuing the drains, antibiotic coverage (if signs of infections present), serial radiological examinations, and drainage of collections is recommended for the treatment of pancreatic fistulae. Use of somatostatin or its analogue may be useful in such situations.

Suggested Reading

1.American College of Surgeons Committee on Trauma. Advanced trauma life support student course manual. 8th ed. Chicago: American College of Surgeons; 2008.

This reference has set standard for initial evaluation and management of the trauma patients by emergency physicians and trauma surgeons.

2.Velmahos GC, Toutouzas KG, Radin R, et al. Non-operative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003;138(8):844–51.

The rate of nonoperative management (NOM) failure for solid abdominal organ injuries in this study is higher than the rates reported in retrospective studies. Nonoperative management is less likely to fail in liver injuries than in splenic or kidney injuries. Use of NOM should be

66 Torso Trauma

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exercised with caution if blood transfusion is needed, fluid is identified on the screening ultrasonogram, or a significant quantity of blood is discovered on CT.

3.Harriss DR, Graham TR. Management of intercostal drains. Br J Hosp Med. 1991;45:383–6.

Intercostal tubes are inserted to treat several intrathoracic calamities. This report outlines the correct procedure for managing intercostal drains and describes the complications that may occur.

4.Miller KS, Sahn SA. Chest tubes. Indications, technique, management and complications. Chest. 1987;91:258–64.

Websites

1.www.guideline.gov

2.www.cdc.gov/injury/index.html

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