STUDY AND MANAGEMET OF BLUNT INJURY ABDOMEN

Dissertation Submitted to the

DR.N.T.R UNIVERSITY OF HEALTH SCIENCES, VIJAYAWADA, A.P.

In partialfulfillment of the regulations for the award of the degree of

M.S.(GENERALSURGERY)

By
Dr.D. SREEDHAR REDDY M.B.B.S
RegNo:130110005

Under the guidance of

Dr.T.GIRIDHAR M.S,

Professor & H.O.D Department of GeneralSurgery

DEPARTMENTOFGENERALSURGERY
RAJIV GANDHI INSTITUTE OF MEDICAL SCIENCES
KADPA -516001,(A.P),INDIA.
2016-2019
 DEPARTMENT OF GENERAL SURGERY
RAJIV GANDHI INSTITUTE OF MEDICAL SCIENCES
KADAPA-516001,(A.P),INDIA.

Certificate

This is to certify that the dissertation entitled“ CLINICAL STUDY AND

MANAGEMENT OF BLUNTINJURY ABDOMEN submitted by Dr.D SREEDHAR
REDDY,RegNo: in partialfulfillment of the regulation laiddown by the N.T.R.
University of Health Sciences, Vijayawada, for the award of M.S.
(GeneralSurgery) during 2016-2019 has been done by him under the guidance and
supervision of Dr.T.GIRIDHAR M.S. Professor & H.O.D. Department of General Surgery,
Rajiv Gandhi Institute of Medical Sciences Kadapa. A.P.

Dr.T.GIRIDHAR M.S, PRINCIPAL

Professor & H.O.D, Rims,Medical College,
Department of Genral Surgery, Kadapa.
i. D P
D
O
H
ugyos&
fS
no
epartm
Rims,Medical College,
Kadapa.

Place :Kadapa. Place :Kadapa.

Date: Date:
 Acknowledgements
Ithasbeenmyproudprivilegetoworkundertheguidanceofanesteemedteacherand
myguideDr.B.SobhaRani,M.S,D.G.O.,InchargeProfessor,DepartmentofGeneralSurge
ry,SVMC,Tirupati,forhervaluableguidanceduringthisstudyandthroughoutmycourse.Iam
extremelyfortunateandblessedtohavesuchaneminentandinspiringteacher.

IamverymuchthankfultomyProfessor&HODDr.N.V.RamanaiahM.S.,Professors
Dr.B.SrihariRao,M.S.,Dr.K.Manohar,M.S.,Dr.G.V.Prakash,M.S.,&AssociateProfess
orsDr.S.Nagamunaiah,M.S.,Dr.G.Chandrasekhar,M.S.,Dr.R.Hemanthi,M.S.,fortheir
encouragementandhelpthroughoutthiswork.

IamverymuchthankfultoAssistantProfessorsDr.Latchu,M.S.,Dr.Shariff,M.S.,Dr.
Hareesh,M.S.,Dr.K.Vamsidhar,Dr.HariBabu,M.S.,Dr.SrikanthReddy,M.S.,Dr.Keert
hinmayiM.S.,Dr.G.V.Ramanaiah,M.S.,Dr.RojaRamani,M.S.,Dr.Adeppa,M.S.,Dr.Sar
ada,M.S.,Dr.Sabitha,M.S.,inthedepartmentofSurgeryfortheirvaluablesuggestionsinco
mpletingthiswork.

IwouldliketothankDr.K.LokeshM.S,SeniorResident,myseniorPostGraduates,m
yfriendlyColleagues,belovedJuniorPostGraduates,housesurgeonsfortheirtremendous
supportthroughoutthisdissertationwork.

IgreatfullyacknowledgethehelpofnursingstaffoftheDepartmentofGeneralSurger
y.Mydeepestandwarmestgratitudegoestomyparents&friends,fortheirloveandgreatsupp
ort.

Lastbutnottheleast,Iamhighlythankfultomypatientsforprovidingmetheopportunityt
ocarryoutthisstudyandbeinggreatteachersintheprocess.

(Dr.Y.MaheshBabu)
 Declaration
This is to certify that the dissertation entitled “CLINICALSTUDY AND
MANAGEMNT OF BLUNT INJURY ABDOMEN ” submitted by Dr.D
SREEDHAR REDDY in partialfulfillment of the regulation laiddown by the
Dr.N.T.R.University of Health Sciences, Vijayawada, for the a ward of M.S.
(General Surgery) has been done by me under the guidance and supervision
of Professor & H.O.D. Dr.T.GIRIDHAR M.S, in the Department of Genral
Surgery, Rajiv Gandhi Institute of Medical Sciences, Kadapa. A.P.

Place:KADAPA
Date: Dr.D. SREEDHAR REDDY,M.B.B.S.

4
 COPYRIGHT

I here by declare that the Dr.N.T.R.University of Health sciences,

Andhra Pradesh shall have the rights to preserve, use and disseminate this

Dissertation / thesis in print or electronic format for academic / research

purpose.

Place:KADPA Dr.D. SREEDHAR REDDY,M.B.B.S.

Date:

5
 LISTOFCONTENTS

S.No. CONTENTS PAGENO

1. INTRODUCTION 1

2. AIMS & OBJECTIVES OFTHE STUDY 2

3. REVIEW OF LITERATURE 3

4. METHODOLOGY 41

5. RESULTS 43

6. DISCUSSION 58

7. SUMMARY 66

8. CONCLUSION 68

9. ANNEXURE

IEC certificate

Case sheet Proforma

Consent form

Key to master chart

Master chart

References

6
 LISTOFTABLES

S.No. Title PageNo

1. Blunt abdominal and pelvic injury patterns 6

2. Liver Injury – Grading 7

3. Splenic Injury – Grading 9

4. Interpretation of Abdominal Paracentesis 18

5. Treatment of Pancreatic Injuries 32

6. Severity of Small Bowel/Colon Injury 33

7. Age Incidence 43

8. Sex Distribution 44

9. Nature of Injury 45

10. Latent Period 46

11. Associated Injuries 47

12. Signs & Symptoms 48

13. Investigations 49

14. Case Management 51

15. The interval between admission and surgery 52

16. Organs Injured 53

17. Procedures Done 55

18. Post Operative Complications 57

7
 LISTOFFIGURES

S.No. Title PageNo

1. Haemo peritoneum 58

2. Laceration of Liver 58

3. Complete jejunal transaction 59

4. Anastamosis for complete jejunal transaction 59

5. Ileal tear(Case-I) 60

6. Ileostomy for ileal tear 60

7. Laceration of Spleen 61

8. Splenectomy specimen 61

9. Ileal tear (Case-II) 62

10. Resection & anastamosis for ileal tear 62

11. Ileal tear (Case-III) 63

12. Primaryclosureforilealtear 63

13. Gastrojejunostomy fo rgastric tear 64

14. Mesenteric hematoma 64

15. Omental tear 65

16. Mesenteric tear 65

8
 LISTOFGRAPHS

S.No. Title PageNo

1. Age Incidence 43

2. Sex Distribution 44

3. Nature of Injury 45

4. Latent Period 46

5. Associated Injuries 47

6. Signs & Symptoms 48

7. Investigations 50

8. Case Management 51

9. Time Interval between admission and Surgery 52

10. Injured Organs 54

11. Injured Organs 54

12. Post Operative Complications 57

9
 INTRODUCTION

Abdominal trauma is one of the m ost comm on causes

am ong injuries caused m ainly due to road traffic acci dents.
Motor vehicle accidents account for 75 to 80% of blunt
abdominal tram a 1 . Blunt injury of abdom en is also a result
of fall from height, assault wi th blunt objects, sport injuries,
industrial mishaps, bom b blast and fall from riding
bicycle 1 .According to WHO by the year 2020, traum a will
becom e the first or second leading cause of loss of
productive years of life for both developed and developing
countries.

Blunt abdominal trauma is usually not obvious. H ence,

often missed, unless, repeatedly looked for. Due to the
inadequate treatment of the abdominal injuries, m ost of the
cases are fatal. The knowledge in th e m anagem ent of blunt
abdomi nal traum a has progressively increasing due to the
in-patient data gathered from different parts of the world. In
spite of the best techniques and advances in diagnostic and
supportive care, the m orbidity and m ortality remains at
large. The reason for this could be due to the interval
betw een traum a and hospitalization, delay in diagnosis,
inadequate and lack of appropriate surgical treatm ent, post-
operative com plication and associated trauma especially to
head, thorax and extremities.

Unnecessary deaths an d com plications can be

minimised by improved resuscitation, evaluation and
treatm ent. R apid resuscitation is necessary to save the
unstable but salvageable patient with blunt traum a
abdom en 2 .Accurate diagnosis and avoidance of needless
surgery is an im portant goal of evaluation 1 .

In view of increasing num ber of vehicles and

consequentl y road traffic accidents, this dissertation has
been chosen to study the cases of blunt abdominal traum a
with referen ce to the patient presenting at G eneral Hospital,
Rajiv G andhi Institute of M edical S ciences, Kadapa
 AIMS AND OBJECTIVES

1. To evaluate the incidence, nature and various clinical presentations in

blunt injury abdomen
2. To evaluate various diagnostic modalities and freequency of various
abdominal organs incolved in blunt injury abdomen

3. To assess the patient for surgical intervention and to avoid negative

laparatomy.

4. To evaluate modalities of treatement, complications and prognosis.

 REVIEW OF LITERATURE

Historical Aspects

Blunt injury as causes of intra abdominal injuries have been recognized

since histrocal times. Aristotle was the first to record visceral injuries from blunt
trauma. Hippocrates and Galen are said to have given apt descriptio of the
condition.

Sushruta3 described one hundred and one insruments, “of which and is
the most important, in as much as all of them depend on the hand for their
.
principle auxiliary and as none can be habdked without it”.

By 1500 BC distinct triage and surgical protocol had been developed in

Babylonia under the rule of Hammurabi as said by Edwin Smith Papyrus.

In 1580 ambriospare made a refernce of traumatic herniation of stomach

through diaphragm.

The first operative repaire of gastric injury was repoeted by Nollesan in the
18th centurey, and

The first case of gastric injury, as well as resultant fisula, is credicted to

Schenk in the 16th century.

According to Sparkman4 ,Burns was the first to attempt surgical

Treatment of liver wound in1870.In 1882, the American surgeon, Marican

Sims5 advocated and practiced ssurgical intervention in cases of intra abdominal

injuries, but even in 1887,the mortality rate in abdominal wounds were still

77%.

At the beginning of the Boer war in 1889, surgeons in the British army

Had orders to do laparotomies for abdominal wounds, but the results were so

bad that an order was issued to use conservative methods.During the Russo

Japanese war, just 15 years later, conservative treatment was once again

Replaced by operative intervention.

 During the American civil war transportation time was measured in

Days and the overall war mortality was14%.During World WarI,the time from

Injury to surgery was between 12 and 18 hours.The time was reduced during

World WarII between 6 and 12 hours.The average timefrom injury to

Definitive care was further reduced to 2 to 4 hours during the Korean conflict,
6
And the overall Mortality was reduced to 2.4% .

During the Vietnam conflict, the studies showed that the average time

From injury to emergency care was 65 minutes and the overall mortality is

Markedly low 1.8%.

7
Theodore Billroth,1829-1894 was the pioneer for visceral surgery.

1767,NollestonFils reported the first successful repair of agastricinjury.Hes

irrigatedandsuturedastabwoundtothestomach,andthepatientsurvived.

Piacastelli described the first case of blunt gastric rupture in1922.

Aristotle was the first to describe intestinal injury as a consequence of blunt

a bdominal trauma. Hesaid,“ a light blow will cause rupture of the intestines

without injury of the skin”’.

8
Soloman, (quoted by Prout 1968), first described the technique of

Abdominal paracentesis more than 60 years ago. Root et al, first described

the technique of peritoneal lavage in human beings in 1965.

Delayed rupture of spleen was first described by Baudel in1902.

Morris and Bullock in 1919 suggested the importance of the spleen in host

defense, but still routine splenectomy remained the treatment of choice for
9
splenic injury for most of the 20th century .The first splenectomy for trauma

13
in theUnited States was performedby a navy surgeon, O’Brien, in
10
SanFrancisco in 1816 .

The earliest description of herniation of the abdominal viscera through

a traumatic rupture of the diaphragm is credited to Sennertus in1541.Parein

1579 described the clinical manifestations of traumatic diaphragrnatic hernia.

The first report of traumatic rupture of the diaphragm was of a 17 year old
11
boy, reported by Bowditch In 1853. Walker, in 1899, repaired a ruptured

diaphragm secondary to blunt trauma.

12
In 1940, Gray Turner gave valuable advice to those undertaking

laparotomy for closed abdominal injuries as follows: “The patient will not die

froma very big incision, but may very likely succumb if some important injury

isoverlooked.

14
 MECHANISM AND PATTERNS OF BLUNT ABDOMINAL TRAUMA

The most common mode of blunt abdominal trauma is by motor vehicle accedents
followed by accedental fall from height, assault and seat belt injuries 13. In blunt .

abdominal trauma it is very important to elicit the history regarding the

mechanism and various patterns of injury14. Direct impact injuries some times
may be associated with regional injuries also15. Lower right rib fractures will
accompany liver injuries, lower left rib fractures with spleenic
. injuries, mid
epigastric contusion with duodenal and pancreatic injuries and pelvic fractures
with bladder and urethral damage.

TABLE 1 INJURIES ASSOCIATED WITH RESTRAINT DEVICES 16

RESTRAINT DEVICE INJURY

.
Lap Seat Belt • Tear or avulsion of bowel
• Compression mesentery (bucket handle)
• Hyperflexion • Rupture of small bowel or colon
• Thrombosis of iliac artery or
abdominal aorta
• Pancreatic or duodenal injury
Shoulder Harness • Rupture of upper abdominal
• Sliding under the seat belt viscera
(“submarining”) • Intimal tear or thrombosis in
• Compression innominate, carotid, subclavian, or
vertebral arteries
• Rib fractures
• Pulmonary contusion

Air Bag • Face and eye abrasions

• Contact • Cardiac Injuries
• Contact/deceleration • Spine fractures
• Flexion (unrestrained)
• Hyperextension (unrestrained)
 PATHOPHYSIOLOGY OF BLUNT TRAUMA ABDOMEN:

Liver.

Hepatic trauma occurs in approximately 5% of all admissions in emergency

rooms. The anatomic location and the size of the liver make the organ even more
susceptinle to trauma and frequently in blunt injuries17.. Techincal advances in the
last decades resulted in more accurate diagnosis and in better treatement either
operatively or1 nonoperatively,

TABLE NO 2: LIVER INJURY GRADING19

Grade Injury Description

Hematoma Sub capsular <10% of surface area

I
Laceration Capsular tear, <1 cm in parenchymal depth

Hematoma Sub capsular 10-50% surface area, intraparenchymal,

<10cmsindiameter
II
Capsular tear 1-3 cms in parenchymal depth, <10 cms in
Laceration length

Hematoma Sub capsular, >50% of surface area of ruptured

sub capsular or parenchymal hematoma,
III
Intra parenchymal hematoma, >10cms or expanding
Laceration 3cms in parenchymal depth

Laceration Parenchymal disruption involving >75% of hepatic lobe

IV
or >3 couinauds segments within a single lobe.

Vascular Juxta hepatic venous injuries i.e. retro hepatic

V
venacava central major hepaticvein

VI Vascular Hepaticavulsion

16
Spleen

The spleen is the freequently injured organ in patients with blunt injury
abdomin which may present as either subcapsular or intraparenchymal
hematomas or as vascular lacerations. Complete splenic obliteration may lead
to significant hemodynamic instability and subsequent shock.

. Direct blow leads to counter–coup forces, to dislodge the relatively

mobile spleen at its pedicle, from the peritoneal attachement

Splenic injury in children:

Most comon cause of spleenic injury in children is due to injuries while

playing and less commonly due to vehicle trauma. Child abuse to be suspected
in children less than 4 years when reliable history is not available20

Gastric Injuries21

Blunt injuries to the stomach mostly seen in paediatric patients. It is

uncommon in adult patients. Mechanism of injury is due to either rapid
deceleration motor vechical accedents or due to blows in bicycle handle bars

Biliary Injuries22

These are un common after blunt trauma.event show most of the

injuries have associated liver, duobenal and gastric organs. Shearing forces
applied to the right upper quadrant. Can cause traumatic cholecystectomy due
to avulsion of gall bladder from its fossa

17
TABLE NO 3: SPLENIC INJURY - GRADING20

Grade Type Description

I Hematoma Subcapsular, <10% surface area

Laceration Capsular tear, <1cm parenchymal depth

Sub capsular, 10-50% surfacearea,

II Hematoma
intraparenchymal, <5 cms in diameter

Capsular tear,1-3 cms parenchymal depth, which

Laceration
doesnot involve a trabaculae vessel

Subcapsular, >50% surface area or expanding

III Hematoma ruptured subcapsular or parenchymal hematoma,
intra parenchymal hematoma >5cms or expanding

>3 cms parenchymal depth or involving

Laceration
trabaculae vessels

Laceration involving segmental or hilar vessels

IV Laceration
producing major devascularization(>25% of spleen)

V Laceration Completely shattered spleen

Vascular Hilar vascular injury which devascularises spleen

22

18
 Traumatic cholecystitis occurs when direct contusion to the g allbladder

Or haemobilia froml iver injury fills the gall bladder with blood. This blood

stagnates, clots and cannot be expelled from the gall bladder. The cystic duct

becomes blocked and acute distension results.

Extra hepatic biliary trauma

The most common site of duc tdisruption from blunt forces is along the

superior border of the duodenum as the duct enters the pancreas. Shearing

forces across the duct seem to be the most likely explanation, and avulsion of
23
the duct from the papilla is possible.

Small bowel

Injury to Small bowel and mesentery is estimated to account for an incidence

of 1% -5%24. The mechanisms of injuries are crushing, shearing and bursting

forces. Crushing injury is the commonest of all and a violent force is directly
24
applied to the abdomen crushing the intestines between the force and spine .

The second mechanism is tearing or shearing of the bowel and its mesentery

at points of fixation. Tears are common near the ligament of Trietzand

ileo caecal valve where the short mesentery serves as tethering point .Reports

have demonstrated vertical decelerations, by falls or jumps from heights also

injure intestine.

25
Colon and rectum

Colorectal injuries occur in less than 1% of all blunt abdominal injurys

mecanisam of injury may be due to crushing against vertebral column, shearing
injury due to deceleration or bursting due to sudden blow on a distended loop.

19
UrinaryTract

Renal truma occurs in 8%-10% of all patients with blunt abdominal truma
and the most common organ injured in pediatric blunt abdominal injuries,
consequent to upper abdominal injury and rapid deceleratiol. The relative
insidence is more in males than females (10:1) 26

Classification of Renal Injury27

Grade Type of Injury Description of Injury

Contusion Microscopic or gross hematuria , urologic
studies normal
I Hematoma
Subcapsular , nonexpanding without
parenchymal laceration
Hematoma Nonexpanding perirenal hemotoma
II confirmed to renal retroperitoneum
Laceration <1.0 cm parenchymal depth of renal
cortex without urinary extravagation
Laceration <1.0 cm parenchymal depth of renal
III cortex without collecting system , rupture
or urinary extravagation
Laceration Parenchymal laceration extending
through renal cortex , medulla , and
IV Vascular collecting system
Main renal artery or vein injury with
contain hemorrhage

Laceration Completely shattered kidney

V Vascular Avulsion of renal hilum which
devascularizes kidney

*Advance one grade for bilateral injuries up to grade III

 Severe renal trauma is seldom seen as an isolated injury, there
fore,

Can usually be treated with excellent results by conservative measure.

Bladder injuries

The most common cause of bladder injuries in blunt trauma is

from

external violence from motor vehicle accidents, falls, crushing injuries to

the

bony pelvis or blow to the abdomen.The full bladder is especially

vulnerable

to a deceleration injury. In motor vehicle accidents, injuries are seen in

passengers wearing seatbelts with full bladder or secondary to a pelvic

28
fracture

CLINICAL FEATURES OF BLUNT ABDOMINAL INJURIES

13
Splenic trauma: The spectrum of injuries range from the trivial to the
catastrophic.It can manifest as

1.Rapid death: Spleen has been avulsed or severely damaged by

Either a run over or a blast injury.The patient dies before the

Resuscitation can be begun or a laparotomy performed.

2.Shock:The largest group presents with shock, signs of rupture.The

Patients present variable signs of hypovolemia.

3.Delayed rupture:In instances many months after the putative

injury,
 It has been described but the peak of occurrence is within a few
days.

Liver injuries:

Major hepatic injuries are easy to detect because of position of

trauma,

Profound hypotension and marked abdominal distension. A presence of

Un explained hypovolemia occurring with a bloody abdominal

paracentesis,

Contusion of the right upper quadrant or lower anterior chest, referred

pain to

The right shoulder and signs of peritoneal irritation in the right upper
quadrant

Clinches the diagnosis of liver injury.

In closed injury there is much similarity between the presentation

of

Rupture of the liver and rupture of the spleen. The three type’s early
death
inspite of attempts at resuscitation, gradual development of signs of

intra abdominal disaster and frank delayed rupture are all seen but, by

comparison with the spleen, the last is rare. Detection of fractures to over

lying ribs may help to raise the suspicion of an underlying liver injury.

Small intestine injury:

Injury to the lower thorax, abdomen, or pelvis suggests the

possibility

Of small bowel injury. The diagnosis is based up on abdominal pain,

signs of
Peritoneal irritation on physical examination, a positive abdominal tap,
plain X-

ray erect abdomen showing gas under diaphragm and ileus. But‘ A
negative

peritoneal tap and normal X-Ray do not by any means rules out small
bowel

damage, Particularly during the first 24 hours after the injury presents as

peritoneal irritation. Peritoneal iavage may not detect small perforations.

Duodenal rupture15:

A) Intraperitoneal ruptures: These produce the symptoms of rupture of

the

gut. The pain may be greater than usual, but this is not a reliable
indicator.

b) Retro peritoneal ruptures: There may be a significant latent period

in

which the patient feels quite well. However within a matter of some hours
or at

the most a day, severe pain in the epigastrium and back begins and is

associated with intractable vomiting, the abdomen is commonly a little

distended and silent.

Rupture of the large intestine:

Nothing distinguishes colon rupture from that of rupture ofother

Segments of the gut except for the delayed variety of closed caecal
rupture

Where the blow is followed by a latent period, which inturn gives way to
the

Right iliac fossa symptoms and signs, culminating all too often in
catastrophic

faecal peritonitis.

Injuries to the pancreas:

They are rare and are found only in 1-2% cases.The injuries are
often

Diagnosed on exploration for traumatic abdomen with associated visceral

Injuries because the pancreas is surrounded by major abdominal organs

and

Blood vessels.The opening of the lesser sac is very important to rule out
the
30
possibility of pancreatic injury

operative diagnosis of pancreatic injury. Gambil and Mason believed that

the

determination of the urine amylase is a more reliable index of pancreatic

injury
31
than the serum amylase

26
Renal injuries:

Gross or micro scopic hematuria is usually present. These

patients
often have profuse abdominal tenderness,lower rib fractures, vertebral
body

fractures and flank contusions.A palpable abdominal mass with

associated

shock may be indicative of a rapidly developing retroperitoneal

hematoma

from a major renal parenchymal or renal vascular injury. Hematuria may

not

be present, and the diagnosis must be established by radiographic

imaging

prompted by a high index of suspicion.

28
Urinary bladder injuries:

Signs and symptoms of rupture of the bladder are usually non

specific.

The patient may complain of supra pubic pain or relate that he attempted
to
Urinate and could not.Tenderness is present in the supra pubic area and

Bowel sounds are absent, especially if it is an intra peritoneal rupture.

Hematuria is a hall mark finding of bladder injuries.

CARE OF THE VICTIM AT THE ACCIDENT SITE30;

Aim; resiscition and emergency transportation to trauma handling center

as quickly as possible. Paramedical staff accompanying the ambulance
unit should be well trained to resuscitate and shift the patient to
regionalized trauma center as quickly as possible. This is not possible in
our setup. However one should try to move the injured patient to the
nearest possible competent hospital, where resuscitation and definite
care can be started immediately. Mortality can be lowered in the patient
is diagnosed and treated as early as possible.

At the site of accident, the following measures should be taken to

stabilize the patient. Goal of first aid at the accident site would be to
prevent second accident, hypoxia and circulatory failure.

1. Ensure normal airway and ventilation with endo tracheal intubation.

2. Stop or arrest external bleeding,
3. Intravenous fluids.
4. Pneumatic anti shock garments.
5. Protect spine.
6. Splint fractures.

Administration of IV fluids and pneumatic shock garments are subject of

controversy because it may delay the transport of the patient to the hospital

INITIAL RESUSCITATION OF PATIENTS AT CASUALITY:

The goals of management are in the order of priority

1. To save life
2. To save limb
3. To minimize disability
4. Cosmetic care
 Initial management is made by the patient’s immediate physiologic

requirements for survival (i.e.,Airway, Breathing, Circulation,

Disability/ Neurological assessment, exposure for complete
examination) and is

often initiated before the establishment of specific diagnosis. Multiple life

threatening injuries often co-exist, requiring triage with simultaneous

diagnostic and therapeutic interventions.

Primary survey (life-sustaining priorities):

The first priorities are to secure a patent air way and optimize

ventilation, next is to enhance cardio vascular performance. Initially,

hypotension is assumed to be the result of acute blood loss and is

treated
With rapid volume infusion. Refractory hypotension despite rapid
crystalloid

Infusion suggests active bleeding or myocardial dysfunction.Tension

pneumothorax, myocardial contusion and pericardial tamponade are to

be

ruled out for refractory hypotension.

Secondary survey (triage decision making):

A rapid but systemic physical examination is essential to perform,

and

To document inthe medical record. Patientsare completely undressed,

Examined for spinal injuries and then rolled for inspection of their flanks
and
back. Detailed neurologic function, peripheral pulses, rectal examination
for

blood and sphincter tone, inspection of the perineum, back and axilla are

done. A lateral cervical spine radiograph is obtained following major blunt

trauma at the upper torso, neck or head.

Prompt insertion of a Naso gastric tube decompresses the

stomach.

Blood in the gastric aspirate may be the only sign of an otherwise occult
injury

of the stomach or duodenum. A Foley catheter empties the bladder, may

demonstrate hematuria and permits monitoring of urinary output. Occult

regions of major hemorrhage include the pleural spaces, the abdomen,

the

retro peritoneum and skeletal fractures.

Initial abdominal examination of poly trauma patient is notoriously

unreliable indetecting acute intra peritoneal hemorrhage or visceral

perforation. Intoxication, head injury or pain from associated fractures

often

masks peritoneal irritation resulting in a false negative examination in 20-

50%

of acutely injured patients. Similarly, contusion of the abdominal wall

musculature, acute gast ric dilatation, and referred pain from spinal
fractures,
lower rib fractures and pelvic fractures often result in false positive
physical

examination

Investigations in blunt abdominal trauma

1.Four quadrant abdominal tap31:

Accuracy is about 80%. Aspiration of even a drop of blood does not

clot is diagnostic of hemoperitoneum. But a negative tap does not rule
out hemoperitoneum.

2.Ultrasound of abdomen31:

Ultrasound can demonstrate the presence of free intraperitoneal fluid as

well as the extent and precise location of solid organ hematomas.Studies
have shown that DPL was superior to ultrasound in assessing the need
for surgical intervention and ultrasound can be used as complimentary to
DPL in the evaluation of blood injury abdomen.

3.Plain radiography and contrast studies32:

Plain X-Ray abdomen should be done before imagive tests such as

paracenteisis to avoid confusion in detection of free air in peritoneal
cavity.Should include chest AP view supine abdominal and erect
abdominal or left lateral decubitus view, if the patient cannot stand
.Chestradiograph help in detecting thoracic and diaphragmatin injuries.
Air under diaphragm will be found in gastric, duodenal, small intestine
and colonic perforations. Presence of rib, pelvic,vertebral body and
transverse spinous fractures can be made out.

4.Diagnostic peritoneal lavage33:

DPL was introduced by Root et al in 1965. It provbides a rapid,

inexpensive and accurate diagnostic modality in the management of
patients with blunt abdominal trauma.

Indications for DPL

1. signs those are equivocal or obscured by adjacent soft tissue imjury

2. unreliable signs owing to head injury, intoxication or paraplegia.
3. Unexplained hypotension or blood loss even if abdominal
examination is normal.

Relative Contraindications for DPL

1.Only absolute contraindication is a clear indication for an immediate

laprotomy

2. previous surgery

3. gross obesity

4. advanced pregnancy

5. cirrhosis

6. established coagulopathies

It can be done as closed method , open method or semi open

method.semi open method is commonly used.

Criteria for diagnosing peritoneal lavage following blunt abdominal

trauma:

Positive result:

1. More than 5 ml of blood on immediate aspiration

2. Obvious intestinal contents
3. >1,00,000 RBC’s/cmm or 500 WBC /cmm in the drained lavage fluid
4. Elevated amylase levels morethan 20 IU/L and alkaline phoaphatase
>3 IU/L
 TABLENO: 4: INTERPRETATION OF ABDOMINAL PARACENTESIS

Findings Interpretation Organ injury,suspected

Dry tap None Correlate clinically

Non clotting blood Serious injury Spleen,liver

mesentery,retroperitonealh
ematoma

Bilestained fluid Probably positive Rupture of small intestine

Biliary tract

Serous fluid withWBC Probably negative Correlate clinically

5.Abdominal CT scan34:

This can provide important diagnostic information on abdominal injuries

when applied in appropriate setting. It p;ays a complimentary role to
diagnostic peritoneal lavage( DPL). When the lavage is positive but the
patient is stable after resustation and continuos to be even after 30
minutes or when lavage is indeterminant, CT has the potential to
delineate the specific viscus damage.four groups of patients are suitable
for CT scanning.

1. patients with delayed (>12 hrs) presentation who are

hemodynamically stable and do not have overt signs of peritonitis.
2. Patients in whom DPL is equivocal and the results of repeated
physical examination are unreliable.
3. Patients in whom DPL is difficult to perform.
 4. Patients at risk for retroperitoneal injuries in whom DPL is
unremarkable.

Advantages:

It is an excellent means to diagnose intraperitoneal hemorrhage. It

gives excellent views of spleen and liver permitting precise
anatomical diagnosis of solid organ injury.it is also useful in
retroperitoneal injury. Stomach ,duodenum,pancreas can be
diagnosed with high degree of accuracy.intravenous contrast permits
excellent imaging of kidneys and ureters.

Disadvantages:

Retroperitoneal colon injuries is rarely delineated.CT scan is poor for

diagnosis of intraperitoneal hollow viscus injuries and early pancreatic
injuries.Scanning takes a minimum of 45 to 60 minutes which may not be
suitable for unstable paitent.

6.Angiographic studies33:

It was the main tool prior to CT scan and ultrasound. Its use is now
limited for evaluation of solid intra abdominal and pelvic arterial reading
in patients with pelvic fractures. Therapeutic embolization can be carried
when needed. Abdominal aortography or selective visceral arteriography
is useful in the diagnosis and management of intra abdominal bleeding of
laparotomy for trauma. Contraindications are obvious need for
laparotomy, unstable patient or known allergy to the contrast agent. The
primary advantage is to prevent negative laparotomy.

7.Radianuclide imaging31:

This non invasive nature of isotope studies make them attractive as its a
screening procedure. The reduced radiation dosage permits repeat and
follow up studies with safety. But the obvious disadvantages of non
availability in most of the centers and dependancy of the expert
radiologist.

8.Laparoscopy31:

It is the final court of appeal in diagnosing blunt abdominal trauma. It has

distinct advantage over a paracentesis bacause it provides visualisation
of the site and extent of bleeding.

Enzyme studies:

Amylase and alkaline phosphatase levels of the effluent from the DPL
when equal or greater than the serum level is suggestive of injury to
bowel,liver or pancreas.

Routine investigations:

Hemoglobin , hematocrit, blood grouping and Rh typing, serum amylase

and alkaline phosphatase, urine analysis, blood urea, serum creatinine,
blood sugar, chest X-Ray and ECG havce to be done.

TREATMENT AND COMPLICATIONS OF BLUNT ABDOMINAL

INJURIES

Nonoperativemanagement:The use of non operative management

strategies has always been difficult for the trauma surgeon.This approach

has been embraced with fervor in pediatric trauma, whereas specialistsin

adult trauma have been converted only gradually, especially for many
types of

blunt injury. Some advantages of non surgical treatment include less

cost,
 35
fewer post operative complications, and less pain for the patient

Non operative management should be considered only in

hemodynamically stable patients, although the definition of stable

remains

elusive .Between 60% and 70% of blunt solid organ injuries can
. be
managed

non operatively and the succes srateis typically more than 90%35

Successful non operative management was associated with

higher

Blood pressure and haemotocrit, and less severe injury based on injury

severity score, Glasgow Coma Scale, grade of injury and quantity of

haemoperitoneum36

Most of the trauma patients who respond to initial fluid

replacement do

not require surgery.Close monitoring and repeated abdominal .

examinations

can be the main criteria for surgical intervention, although they are not
the

most reliable techniques in the diagnosis of solidorgan injuries in all

patients

and of hollow organ injuries in conscious patients37

Conservative treatment is safe for hemodynamically stable blunt

abdominal trauma patients with solid organ injury but not for hollow
viscus
injury, even if they have extra abdominal injuries. The existence of extra

abdominal injuries, however, prolongs the hospital stay and increases the
38
Need of the blood transfusion

A large intra peritoneal fluid accumulation on ultrasonography in

combination with unstable vital signs is sensitive for determining the

need for

exploratory laparotomy in patients presenting with blunt trauma39

Resuscitation in the emergency room for the patient with

abdominal

trauma should focus on restoration of the air way, mechanics of

breathing and

circulation.

Conservative line of treatment: Patients were kept nil by mouth,

I.V.

Fluids were given. Continuous or 2 hourly naso gastric suction was done.

Parenteral antibiotics are given. Pulse and blood pressure werere corded

every half hourly. Abdominal girth record was maintained. In put and Out
put

charts were recorded.

During the conservative line of treatment, reliance was given on

pulse
 rate , temperature, and intensity of pain in abdomen. When there was
raising
pulse rate ,increased abdominal distension and tenderness, these
patients

were subjected for surgery.

In patients with blunt abdominal trauma who require exploration,

Intravenous antibiotics are certainly justified in the preo

perativeperiod.There
44
is no convincing data that post operative antibiotic coverage is useful in
the .

absence of contamination from the gastro intestinal tract40

The hemodynamic response to crystalloid or colloid infusion in

blunt
.
Abdominaltrauma is primarily dependent on the severity of injury and the
rate

of fluid resuscitation41

Operative Management:

Indications:

1.The presence of hemorrhagic shock and physical findings consistent

with abdominal injury.

2.Evidence of hollow organ rupture on radiologic studies

3.Gross abdominal wall defects (excluding simple lacerations), rapidly

Increasing abdominal distention

4.Un correctable hypotension and isolated rigidity on abdominal

42
examination in anotherwise intact and co-operative patient.

Conduct of the operation35:

Abdomen is opened with midline inscision

Large amounts of blood may been countered after entering the

abdomen.All

Four quadrants should be rapidly packed and clots are evacuated

manually.
Examine systematically to identify source of bleeding. Haemorrhage
controlis

the first priority in managing abdominal trauma. The next priority is

control of

gastro intestinal spillage.

13
Formal laparotomy is carried out by eviscerating the entire bowel from
the

Abdominal cavity which permits the pelvic contents to be seen and the
floor of

the pelvis to be cleanly sucked out.

Inspect around the descending, transverse, ascending colon and

leading on to the whole small bowel. Next, the colon is displaced down
wards
and the spleen and left diaphragmatic cupola are examined. The
stomach is

then both exposed and palpated, and the left and right lobes of the liver
with

gallbladder and finally the anterior surface of the duodenum and

pancreas

are examined. Finally, if injury from behind has occurred or a missile

tract

from infront suggests the need to open the lesser sac below the stomach
and

the pancreas is examined.

The right colon and duodenum are mobilized by a long incision in

the

Posterior parietal peritoneum of the right para colicgutter stretching from

the

bottom of the right iliac fossa to the under surface of the liver. This also

serves to expose the right kidney, although significant injury to either of

these

organs is usually manifest soon after the abdomen has been opened
because

of the presence of a retro peritoneal hematoma.

The basis of damage control surgery rests on quick
control of life-threaten‐ ing bleeding, injuries, and
septic sources in the appropriate patients before
restoring their physiological reserves as a first step
followed by ensuring of the physiological reserves
 and control of acidosis, coagulopathy, and
hypothermia prior to complementary surgery.

1. When should damage control surgery be done?

Indications for patient selections for damage control
surgery40

Knowing when to perform damage control surgery will increase the

likelihood of survival. There are four main topics that are important in
the selection of patients: (1) critical physio‐ logical factors, (2)
complex injury causing the loss of physiological reserves, and (3)
other conditions in trauma patients

1.Critical psychological factors

a. hypothermia (350 c)

b. acidosis (pH <7.2 or base deficit > 8)

c. coagulopathy

d. prolonged time for definite surgery (> 90 minutes)

e. hemodynamic instability or pre-existing hypoperfusion

2. complex injury associated with loss of physiological reserve.

a. high energy blunt trauma

b. multiple penetrating injuries

c. visceral injury combined with major vascular trauma

d. injuries passing through body cavities.

Acidosis, acquired coagulopathy, and hypothermia (death triangle/the

lethal triad) which are among critical physiological factors come to the
fore in patient selection. There is a multivariable relationship between
these three basic conditions41. Also the hypotension that occurs
emerges as an important parameter in patients on whom damage
control surgery is being planned to be done.
High-energy blunt traumas that can lead to the depletion of
physiological reserves, those with a large number of penetrating
injuries, injuries where more than one compartment is affected, and
injuries where visceral organ and vascular injuries have occurred
together are indicators for damage control surgery7
In patients predicted to undergo damage control surgery, a
replacement with crystalloids is applied after establishing a wide
vascular access before reaching the hospital. The main goal of
replacement therapy, especially applied to patients whose
transportation to the hospital will be prolonged, is to maintain
acceptable vital functions until reaching the hospital42..

2. The death triangle (the lethal triad)

It consists of hypothermia, acquired coagulopathy, and acidosis and

was defined for the first time by Burch et al42. This condition gives rise
to the depletion of physiological reserves and to life-threatening
consequences (Figure 1).

Figure 1. The death triangle (the lethal traid).

Hypothermia

Extensive injury as well as the resuscitation wherein we performed

massive transfusion also contributes to its formation. Tissue
hypoperfusion due to serious bleeding occurs and deteri‐ oration of
oxygenation occurs as a result. Consequently, hypothermia occurs41.
 In particular, the hypothermic condition continuing below 36°C for a
long time (longer than 4 h) becomes clinically significant. Mortality
rates rise up to 100% in patients with multiple injuries and whose
body temperature is below 32°C. The decrease in oxygenation and in
tissue perfusion due to bleeding in particular plays a role in its
formation 44.
If hypothermia persists, it leads to cardiac arrhythmia, decrease in
cardiac output, increase in systemic vascular resistance, and a
leftward shift in the oxygen dissociation curve in the long term. It also
leads to the impairment of the immune system and its suppression as
a result of this45.
It also deepens acquired coagulopathy, which is another important
issue (with a decrease in the activation of coagulation factors, platelet
dysfunction, impairment of endothelial perme‐ ability, and stimulation
of the fibrinolytic system). This results in uncontrolled bleeding.

Coagulopathy

The balance between bleeding and bleeding control mechanism is

disrupted due to trauma. Although there are many underlying factors,
massive transfusion and hypothermia are important
.
Especially in hypothermic patients, it leads to platelet dysfunction by
disrupting the interac‐ tion between von Willebrand and the platelet
glycoprotein 1b-IX-V complex. A decrease in the metabolic rate of
coagulation factors occurs below 35°C46.
Massive blood transfusions lead to hemodilution and the aggravation
of coagulopathy and acidosis due to this.
Although prothrombin time (PT), partial thromboplastin time (PTT),
and fibrinogen levels help, clinical suspicion is essential for diagnosis.
In particular, extensive hemorrhages not due to surgical causes (such
as from injuries, serosal surfaces, and the skin) help in making a clinical
diagnosis 41.

Metabolic acidosis

In trauma patients, anaerobic respiration increases and lactic acidosis

arises due to prolonged hypoperfusion. It gets aggravated with
multiple blood transfusions, aortic clamping, and insufficient
myocardial functioning. As it gets aggravated, it increases
coagulopathy and due to this also hypothermia41.

3. Stages of damage control surgery

Stage I (rapid/primary surgery)

Rapid surgery is applied with the purpose of controlling bleeding and

contamination. The abdomen is entered with a midline incision
extending from the xiphoid to the symphysis pubis. With the purpose of
controlling bleeding and hemostasis, packing, clamping, ligation, and

shunting procedures are performed to the four quadrants or a

balloon catheterization is done 47.
Following hemorrhage control, the colon and intestines are examined
with the aim to pre‐ vent contamination. If perforation is observed,
contamination is tried to be prevented by primary suturing and
connecting or with a stapler. If the injured small intestine loop is be‐
low 50%, a simple single resection can be applied. Ensuring
continuity of the bowel is not in the foreground. In the case of a biliary
or pancreatic injury, closed absorbent systems and external drainage
procedures are preferred. However, reconstructive surgeries, stoma
form‐ ing, and nutrition ostomies are not applied in this quick
laparotomy 41.
Before the abdomen is closed, the inside of the abdomen is washed
with warm solutions.

Then, abdominal closure (temporary abdominal closures; TAC) is

done with the Baker technique, which today has taken the place of
methods like the Bogota bag and clamping of the skin. Plastic-coated
abdominal covers are laid in such a way as to protect the visceral tissues
beneath and closed absorbent systems are laid on this plastic cover at
the level of subcutaneous tissue. Meanwhile, the skin is protected.
Ready kits are available for this technique (KCI V.A.C. and ABThera,
Kinetic Concepts, Inc., San Antonio, TX; Renasys systems, Smith &
Nephew, Inc., St. Petersburg, FL). In this way, the tension that causes
abdominal compartment syndrome is reduced 40.
In a septic abdomen, primary surgical treatment mainly focuses on
controlling the contami‐ nation. To this end, resections and drainages
are carried out. According to the source (hollow organ injury,
pancreatic injury, or hepatobiliary injury), a wide source control can be
ensured with a vacuum-aided TAC as in a trauma 40.
 Stage II (resuscitation)

Following primary surgery, patients are taken into an intensive care

unit for a period of 24–48 h for the enabling of aggressive resuscitation
and patient monitoring. The main objective here is the elimination of
problems caused by the acidosis, coagulopathy, and hypothermia
triangle40,41.
First, it is planned for the patient to be brought close to the euvolemic
state to ensure end-organ perfusion. For this purpose, the patient is
given blood products (such as erythrocytes and fresh frozen plasma
[FFP]). The shock of the patient gets tried to be ameliorated with fluid
resusci‐ tation. Following these, techniques such as artery
catheterization and pulse artery catheteri‐ zation are applied41.
The hypothermic condition of the patients is important because
hypothermia can cause acidosis and coagulopathy to deepen. The
control of hypothermia begins with the quick termination of the initial
operation. The quick removal of wet covers from the patient, raising of
the room temperature in the operation room, the use of warm
resuscitation fluids and ventilator air and heat regulating covers help
warm up the patient in the initial surgery room. The patient should be
exposed to heat for about 4 h before being taken into the intensive care
unit. Pleural lavage can be applied to patients whose body
temperature does not rise despite

the methods applied. If the body temperature continues to be low,

continuous arteriovenous heating can be applied 48.
Coagulopathy is the goal as a secondary objective. For this purpose,
blood products and resuscitation are planned for the patient. In the first
24 h, replacement is applied to the patient according to the rule of 10s
(10 units for erythrocyte suspension, fresh frozen plasma, and
platelets each) 41. Replacement is continued until 1 PT period is 15 s
and the platelet number is 100,000/mm3. If fibrinogen levels are low,
cryoprecipitate can be applied every 4 h. In life- threatening
 nonsurgical hemorrhages, recombinant factor VIIa can be applied41.
If sufficient resuscitation is ensured and the patient is exposed to
heat and oxygenation is ensured, then oxidative respiration increases
and the acidosis is corrected by itself 49.

Stage III (definitive/complementary surgery)

Following 24–48 h of resuscitation after primary surgery in intensive

care, planned definitive surgery is performed 40. First, the packing materials
of the patient are carefully removed. After which all injuries are detected
and any hemorrhages are stopped. Complementary gastroin‐ testinal
repair (such as resections and anastomoses) is done and if it is not
necessary, then ostomy and the opening of enteric feeding tubes are
avoided.

After the inside of the abdomen is cleaned, closed system drainages are
placed if necessary. A nasoenteric feeding tube is placed if necessary,
and if abdominal closure cannot be fully done, temporary abdominal
closure is done40. Rapid closures, moderately rapid closures, and long-
term closures are among temporary abdominal closure techniques
(Table 2).
Closure options for abdominal injuries 40.

1. Rapid closure

a. Only skin closure

b. Placing a protective element such as a Bogota bag
c. Vacuum aided abdominal covers.

2. Moderate closure
a. Successive skin or fascial closure
b. Placing of interpositional mesh
c. Vacuum aided abdominal covers
3. Long term closure (planned ventral hernia).

In patients with a septic abdomen, the septic source is debrided and

drainage is applied. However, in order to avoid problems like abdominal
compartment syndrome, relaparatomies or a planned relaparotomy can be
done [7].

Stage IV (abdominal wall closure)

It is applied on patients whose abdomens could not be closed in definitive

surgery and on whom temporary abdominal closure techniques are applied47
(Figure 2).
The stages of damage control surgery.
HEPATIC INJURIES:

Non operative therapy: Several authors have reported on successful non

surgical management of intrahepatic hematomas ’due to blunt trauma

18
That are not expanding and will ultimately resolve spontaneously. Grade I

And grade II hepatic injuries identified by CT can be treated non surgically.

Patients with more severe injuries documented by CT who is

hemo dynamically stable, whose positive findings on physical examination are

restricted to the right upper quadrant and in whom there is no areas on to

suspect an associated intra abdominal injury may be cautiously selected for

47
.
non operative therapy

bile collections, or abdominal abscess in the non operative group.The grade

of hepatic injury as diagnosed by CT scan does not predict the need for

surgery

18
Operation: The abdomen is explored through a midline upper abdominal

incision.The presence of blood and clots in the right upper quadrant may

signal the presence of a hepatic injury. When these clots are removed,

inspection and palpation may identify the fracture or disruption of hepatic

substance.If the fracture to the liver is located or extends posteriorly on the

dome and approaches the retro hepatic region near the vena cava, an injury

to the hepatic veins must be suspected.

If there is suspicion of gradeV or VI injury, a decision must be made at

this time as to whether to open the chest for exploration of the retro hepatic

area or to insert gauze packs.

 18
Surgical hemostasis

Pressure on the edges of the hepatic wound may temporarily control

bleeding from a vessel near the surface (gradeIorII).

Pringle manoeuvre: The left thumb is placed on the anterior surface of

The hepato duodenal ligament and the middle and index fingers inserted in to

The foramen of Winslow. The structures in the porta hepatis are compressed

Until a non-crushing vascular clamp can be placed across the porta hepatis.

Post operative course18: Cases of major hepatic injury will manifest

Post operative derangement of hepatic function. Serum bilirubin and serum

aspartate transferase and alanine transferase levels are elevated early in the

postoperative period whereas the alkaline phosphatase levels tends to rise

and the serum albumin level to fall after first 10-14 days.

When a resection is performed, certain metabolic derangements can

occur post operatively such as deficiency of coagulation factors,

hypo glycemia and hypo albuminaemia. Nutritional support is essential in all

cases of severe liver injury.If oral alimentation is not started within 3-4 days,

parenteral alimentation should be initiated. The closed suction drains should

be removed as soon as the purpose for which they were placed is

accomplished.

48
MANAGEMENT OF SPLENIC TRAUMA IN ADULTS

Diagnosis: The classic findings of referred left shoulder pain (Kehr’ssign)

and left upper quadrant dull ness to percussion that changes with alterations in

position (Balancesign) usually are not demonstrable. Importantly, the patients

who have an equivocal or normal physical examination despite a high index of

suspicion of spleen injury should have further evaluation, usually an

abdomina lscan.
Non operative management: The patients should be placed on bed rest.

The gastro intestinal tract is decompressed with a nasogastric tube only in

patients who have vomiting, retching; or gastric distension. Frequent

examination and hemoglobin determinations are mandatory. These tests

should be done every 8 to12 hours in patients with gradeI injuries and every

6 to 8 hours in patients with more severe splenic injuries. Improvement in the

Physical examination and stabilization of the hemoglobin value suggest that

non-operative management has been successful.

When proper selection criteria are applied, non-operative management

is successful in 70 to 80% of patients.The most common reason for these

patients to need operation is evidence of persistent bleeding from the spleen.

Missed injury to another intra abdominal organ is un usual.

49
.In many instances, splenic injuries form only a part of intra
Operative treatment remains an important component of therapy for splenic
Multiple trauma. Hence an exploratory laparotomy has an
injury. A midline incision provides easy access for general exploration
50
of the
.
abdominal cavity and its contents. The primary goal of operation for splenic

injury is to control hemorrhage.

The spleen is explored initially by careful palpation.Massive bleeding

From the spleen usually can be controlled by manual compression of the

parenchyma. If it fails, the splenic pedicle is grasped between the thumb and

fore finger while the spleen is being mobilized. The spleen is mobilized from

its surrounding attachment to the diaphragm, kidney and colon and the

splenic artery and vein are approached from the posterior aspect just lateral

to the pancreatic tail.

After repair or removal of the spleen, the left upper quadrant is

Thoroughly irrigated, and the splenic fossa is packed with a dry sponge.The
sponge is then removed and bleeders if any are cauterized or ligated.

Inadequate hemostasis inthis area contributes to the developing of a post

Operative subphrenic abscess.

Complications:The major complications of splenic preservation and

splenectomy are sub phrenic abscess and post operative bleeding.

Impairment of splenic venous drainageafter splenic repair or resection may

Result in splenic infarction. After splenectomy, patients should be immunized

With multivalent
21
pneumo coccal vaccine before they are discharged.
.
MANAGEMENT OF SPLENIC INJURY IN CHILDREN :Crucial to the safe

management of the child with the injured spleen is an appreciation of when

non invasive evaluation techniques and a non operative approach can be

21
nor specific for the diagnosis of gastric injury .The

applied safely 51
.
abdominal

advantage over the non operative conservative management

Once isolated splenic injury is confirmed, admit the child in to

Intensive care unit. Continued close monitoring of vital signs and urine out put

to establish presence of on going blood loss is made. Foley catheter is

placement. Nasogastric suction is done until the returnof gastro intes tinal

function. Serial haemotocrit values are determined. Angiographic approach

for ongoing blood loss can be made. Absolute bed rest for 7–10 days is given

and activity for 6 weeks to 3 months is restricted.

Return to normal activity with CT evidence of complete splenic healing

or stable CT appearance of the spleen. If the patient has undergone

splenectomy the administration of pneumovax and H.Influenza vaccine and

life long prophylactic oral penicillin are recommended therapy.

MANAGEMENT OF GASTRIC INJURIES:

Incase of full-thickness gastric perforation, spillage of gastric contents

in to the free peritoneal cavity results in generalized tenderness, guarding and

rigidity

Hematemesis or aspiration of blood from nasogastric tube suggests

gastric injury. Pneumoperitoneum can occasionally be observed on plain

films of abdomen after gastric perforation.Routine laboratory analysisis

neither sensitive

mechanism of injury, location of injury and type of repair used all affect patient

outcomes with gastricinjury

21
TREATMENT OF GASTRIC INJURIES:

After entry in to the abdominal cavity by midline laparotomy the

Abdomen is packed with pads and maj or hemorrhage if present is controlled.

Rapidly place sutures to halt spillage of gastric contents during the initial

stages of a major operation.

.
Examination of the stomach must be thorough.Care must be exercised

to avoid injury to the spleen with down ard mobilization of the stomach. The

lesser sac and posterior surface of the stomach should be directly visualized

by dividing the gastro colic omentum. Hematomas of the stomach wall,

especially along the greater and lesser curvatures should be evacuated and

thoroughly explored. As with injury to any hollow viscus, the presence of a

single wound should prompt a meticulous search for a second wound.

 As a consequence of its largesize and ample blood supply, most

wounds of the stomach are amenable to local, primary repair, by either hand
53
sewn or stapling techniques. Occasionally,
. extensive gastric wounds require

gastric resection. If an injury to the Vagus nerve is suspected, as occasionally

encountered in wounds of the lesser curvature or the region of the esophago

gastric junction, a drainage procedure should be performed.

MANAGEMENT OF DUODENAL INJURIES:

Diagnosis: The diagnosis is often delayed, despite appropriate workup of

patients with potential injury and careful monitoring of such patients by

experienced surgeons. Isolated smal lbowel and mesentery injuries (SBMI)

are common, however and special attention to the mechanism of injury,

abdominal examination, presence of hematuria, and significant base deficit

should raise suspicion to the possibility of SBMI. Mortality however, does

appear to be related to the presence of hypotension on admission and

52
Associated injuries

Routine laboratory tests and plain films are nonspecific for duodenal

injury.Free air is an unusual finding that is seen in less than 10% of cases

and evidence of retro peritoneal air may be absent in more than 50% of

patients with duodenal rupture. Isolated blunt injury of duodenum is more

difficult to diagnose than penetrating injuries it may also occur with pancreatic

injury. Despite progression of the imaging techniques, the diagnosis still

remains critical and may be delayed in particular, when there is perforation

of retroperitoneal part of duodenum

54
Duodenal injury can be graded upon its severity as follows

TypeI– Sero muscular tear,intra mural hematoma

TypeII- Full thickness laceration

TypeIII– Associated with contusion, hematoma or laceration of the

pancreas.

TypeIV– Combined severe pancreatico duodenal injuries

To establish a diagnosis of duodenal rupture pre operatively is difficult,

especially if it is purely retro peritoneal. This is attributed to delayed

manifestations of symptoms and physical findings because injuryis

retroperitoneal, contents are in Neutral pH and sterile.

21
Operative management

Several factors must be considered when choosing an operative repair

S trategy like extent of injury, presence of associated injuries to the pancreas

Or bile ducts, time from injury to repair and physiological status of the patient.

Techniques of repair: Most duodenal injuries are amenable to simple

Debridement and two- layer repair with a running, full thickness, absorbable

suture followed by the placement of Lambert sutures.If the duodenum is

completely transected, the wound edges may be debrided, and a two layer

primary anastamosis may be performed. If a large defect is present in theLateral

duodenal wall, due to injury or necessary debridement, attempts at

primary closure may lead to either significant luminal narrowing or a repair

undertension. In such cases, a patch closure rather than primary repair may
be required.

21
Complications:The most serious complication specific to the repair of injury to

the pancreaticoduodenal complex involves break down of the duodenal repair

with fistula formation and abdominal sepsis. Pancreatitis or pancreatic fistula

may rarely develop after blunt duodenal trauma despite thea bsence of evident

pancreatic injury. Intra abdominal sepsis can follow the repair of duodenal injury.

55
MANAGEMENT OF PANCREATIC TRAUMA:

Pre operative evaluation: The pre operative evaluation of patients with

possible blunt pancreatic injury requires a careful history. Serum amylase

levels are often obtained in the initial evaluation of blunt trauma, and any

elevation requires follow- up, ranging from repeated physical examination to

additional imaging studies. Endoscopic retrograde cholangio pancreatography

(ERCP) can identify pancreatic injuries; but it is not used in the immediate

post injury period.

The principles of managing pancreatic injuries are straight forward and

include debridement of devitalized tissue, identification and control major duct

injuries, preservation of sufficient pancreas for endocrine and exocrine

function, providing adequate internal or external drainage for pancreatic

secretions ,obtaining access for enteral feeding distal to repair and

anastamosis.

TABLENO:5:SELECTIVETREATMENTOFPANCREATICINJURIES
 Class Injury Treatment

I Minor contusions and lacerations Externa ldrainage

II Major contusions and lacerations External drainage Distal

with intact major duct Pancreatectomy

III Distal transection or major duct Distal pancreatectomy (Consider

injury spleen preservation)

IV Proximal injury with major Extended distal pancreatectomy

duct injury
V Massive disruption of
pancreatic head or pancreatic–
duodenal complex
56
:
Resect (or drain) pancreas,
exclude duodenum; consider
Pancreatico duodenectomy.

Complications:

Fistulas: 25% to 35% of significant injuries to the pancreas result in a

pancreatic fistula .Most of these injuries are minor and resolve spontaneously.

Continuous drainage is essential until the pancreatic leak abates, as generally

occurs within 2 weeks of the injury.

Abscess :True pancreatic abscesses are seen in fewer than 10% of patients

with significant pancreatic trauma, and these lesions usually result from

inadequate debridement at the time of surgery.

Pseudocysts: Unlike Pseudocysts secondary to chronic pancreatic disease,

pseudocysts that develop after pancreatic trauma are often definitively

treated by per cutaneous drainage.

MANAGEMENT OF COLON INJURIES:

Colonic or rectal injuries occur in upto 10% of severe blunt abdominal

trauma.The vast majority of colon injuries can be primarily repaired with a

significant trendt oward avoiding colostomy whenever possible. Colostomyis

increasingly reserved for rectal injuries and destructive colon injuries with

extenuating circumstances such as hemodynamic instability and significant

57
associated injuries.

TABLENO 6: SEVERITY OF SMALL BOWEL OR COLON INJURY

Grade Description of injury

Intra mural hematoma

63
.
1 Partial thickness laceration

2 Small perforation, <50% circumference

3 Large perforation, >50% circumference

4 Complete transection

5 Transection with devascularized segment

Primary repair can be done in more cases than is routinely done.The

presence of multiple abdominal injuries or shock does not exclude primary

repair. The site of injury may affect the out come, but does not exclude primary

repair. Gross fecal contamination, extensive colonic damage and type of

feces in affected colon should be considered as indications favoring

58
colostomy.

In contrast to small bowel perforation, delay in operative intervention

61 59
.
appears to be less common but is still associated with serious morbidity
.Pathologic lesions of the

RENAL INJURIES:
 26
Management of renal injuries: Patients with gross hematuria or micro scopic
hematuria associated with shock should have ultrasound staging studies. Any
degree of hematuria following trauma demands attention, microscopic hematuria
alone following, blunt abdominal trauma need notmandate emergency

Investigations: CT scan: can indirectly detect major vascular injuries and

segmental artery injuries. The major limitation of CT is the lack of detection of
venous injuries to the main renal vein or its segmental branches.

IVP: In patients with out a pre operative abdominal CT scan, an intra operative

intravenous pyelogram is obtained. Standard IVP with multiple images, as would

be done to evaluate non traumatic upper tract disease is not done . Intra

operative IVP canusually be performed with minimal disruption to the surgical

team’s efforts to stabilize the patient and is used notonly to identify injuries, but

also to confirm a functional renal unit on the injured side and to determine the

presence of urinary extravasation, which can be difficult to detect

intraoperatively. It also can exclude the need for renal surgery if findings are

absolutely normal and there is only a non pulsatile non expanding Heamatoma.

Management: Conservative management of major blunt renal trauma is

appropriate in hemodynamically stable patients

urinary tract are uncommon; however, they may complicate an otherwise

negligible renal trauma. The diagnostic and therapeutic approach to blunt

renal trauma must be modified in these cases. A high index of suspicion must

be maintained when a patient presents with gross hematuria with a minimal

62
force blunt abdominal trauma
 26
Indications can be absolute and relative:

Absolute: Expanding or un contained hematoma and pulsatile hematoma,

which might indicate the presence of grade V injury

.Relative: Urinary extravasation, vascularinjury, non viable parenchyma, and

incomplete staging

26
Vascularinjury:

Vascular injury of major renal vessels has been reported in 1% to 3%

of patients with blunt renal injuries. Total avulsion of the renal artery and vein,

seen after rapid deceleration is the most serious injury because of acute

hemorrhage. When non visualization is found on excretory urography,

immediate arteriography or CT is indicated.

26
Retro peritoneal Heamatoma:

Exploring the kidney that is surrounded by heamatoma has been

regarded as hazardous and complete nephrectomy often has followed. High

dose excretory urography should be performed on the operating room table to

evaluate the status of the potentially injured kidney and confirm the presence

of a functioning contra lateral renal unit. If the excretory urogram appears

Normal and no continued expansion of the hematoma is noted, surgical

exploration can be avoided. How ever, when excretory urogram is

inconclusive, surgical exploration of the hematoma should be performed.

26
Operative exploration and renal exposure: The preferred approach is a mid

line, trans abdominal incision. This allows assessment of other intra abdominal
visceral organs and major abdominal vessels. To control massive bleeding

before renal exploration, it is important to isolate the renal artery and vein

individually. Once vessel isolation is complete, an incision is made in the

peritoneum just lateral to the colon, and the colon is reflected medially to expose

the retro peritoneal hematoma in its entirety. The kidney should be totally

exposed and mobilized for complete inspection.

26
Operative findings and renal reconstruction:

Parenchymal injuries: Large intra renal hematomas that reside in lacerations

shouldbe completely evacuated and the margins of the laceration inspected.

All non viable tissue should be completely removed. Hemostasis should be

Achieved on lacerated margins. The collecting system in the depth of renal

laceration should be inspected. If open, interrupted sutures of 4-0 chromic or

4-0 polydioxanone should be used. Closure of the renal parenchyma over the

repaired collecting system provides another barrier to urinary leakage.

In severe cases of renal injury with out preservation of capsule, the

entire kidney can be wrapped in a poly glycolic acid (Vicryl) mesh plug. This

technique holds the injured kidney to gether until it heals. Retro peritoneal

drains are left in place when there is a question of urinary leakage.

26
Complications:

Early complications: Occur within 4 weeks of injury and include delayed

bleeding, abscess, sepsis, urinary fistula, urinary extravasation and urinoma,

and hypertension. Delayed bleeding can occur from the immediate post

operative period until several weeks later. Angio embolisation is the primary
treatment for delayed renal bleeding after trauma, but speedy nephrectomy

may be required if bleeding is brisk. Abscess may develop in perinephric

space and in most circumstances is noted with in the first 7days. CT scan aids

in establishing the diagnosi s and extent of extravasation.

Late complications: Arterio venous fistula, hydro nephrosis, calculus

formation hypertension, chronic pyelo nephritis. To detect many of these

developing delayed complications, a CT scan is strongly recommended with in

3 months of major renal injury.

Conservative management with timely percutaneous or endoscopic

Intervention in patients with major renal injuries results in minimal loss of renal
63
tissue without significant late complications

28
MANAGEMENT OF URINARY BLADDER INJURIES:

Radiographic examination: The static cystogram is the only study that will

Definitely diagnose a ruptured bladder.

Bladder contusion results from damage to the bladder mucosa or

muscularis with out loss of wall continuity. Extravasation is not seen on

cystogram, but the bladder outline may be distorted. It necessitate catheter

drainage for a few days or, if minor, no therapy at all. If there is a large pelvic

Hematoma and marked bladder neck distortion, the patient may have difficulty

In voiding.These patients may require prolonged catheter drainage.

Classification of bladder injuries due to blunt trauma:

1.Contusion
 2.Interstitial rupture

3.Intra peritoneal rupture

4.Extra peritoneal rupture

5.Intra peritoneal and extra peritoneal rupture

Interstitial rupture: Occasionally, an incomplete tear of the bladder wall is

seen secondary to blunt trauma. It is important to distinguish this injury from a

bladder contusion because the therapy requires a longer period of

catheterization because it may represent a full thickness injury that has

sealed with clots or atleast needs a longer time to heal as a result of the

extent of the damage to the bladder wall.A cystogram should be performed

before catheter removal.

Intraperitoneal rupture: It occurs when there is a sudden rise in

Intravascular pressure secondary to a blow to the pelvis or lower abdomen.

This increased pressure results in rupture of the dome, the weakest and most

mobile part of the bladder. Contrast material will fill the cul de sac, outline

loops of bowel, and eventually extend in to the para colic gutter. All intra

peritoneal bladder ruptures caused by blunt abdominal trauma should

under go formal repair.

Extra peritoneal rupture: Extra peritoneal bladder ruptures are seen almost
exclusively with pelvic fractures. Isolated un complicated extra peritoneal bladder
ruptures can be handled easily by 10 days of foley catheter drainage. If the
catheter will not drain easily and the urine doesnot clear properly. formal repair is
tbe best option.

Intra peritoneal and extra peritoneal ruptures: These injuries need to be

formally repaired. Most of these patients have major pelvic fractures and often
have injured their urethra, bladder neck, or in the female, vagina as well. Prompt
reconstruction, even in the face of a marked pelvic disruption, is

14
Usually necessary for a good long term results.

MANAGEMENT OF DIAPHRAGMATIC INJURIES:

In the absence of respiratory distress and massive visceral herniation,

The diagnosis of blunt diaphragmatic disruption can be difficult. Because of

diagnostic delay and strangulation mortality and morbidity is being increased.

Victims of lateral impact motor vehicle collisions are more likely to

experience rupture of the diaphragm than victims of frontal collisions.

Occupants exposed to left lateral impacts a greatest risk. The sid eof

Diaphragmatic rupture correlates with the direction of impact. The right hemi

diaphragm is more resistant to rupture.

Chest radiography and diagnostic peritoneal lavage will establish the

Correct diagnosis in almost 90% of cases. Additional diagnostic studies are

Reserved for the remaining 10% of patients. Due to the pressure differential

Between abdomen and thorax, once the diagnosis has been established, the
64
treatment of every diaphragmatic disruption is surgical repair
Diagnostic laparoscopy and or diagnostic thoracoscopy should be

performed to confirm or rule out this injury. Factors suggestive of a right

diaphragmatic tear include newly or progressive4elevation of the right

diaphragm and respiratory distress without underlining lung injury. The timing

of the procedure should be in accordance with the hemodynamic and

respiratory status of the patient. This procedure should be performed semi

65
electively if there are no other indications for surgical intervention.

METHODOLOGY

This study is a prospective study on 100 patients with Blunt injuries to

the abdomen admitted in Govt General Hospital, RIMS, Kadapa during the

study period of 3 years.

Inclusioncriteria: Patients>16 years,withBluntinjury toabdomen either by

RTA,fall,objectcontact,assault giving written informed consent.

Exclusioncriteria:Patients<16 yrs,Bluntinjuries due to blasts,patients with

severe cardiothoracic and head injuries who are hemodynamically unstable.

Patients fulfilling the inclusion and exclusion criteria are selected.

Written and informed consent is taken.Demographic data like name,age,

sex,occupation,economic status,literacy status noted.Nature of injury,time

of event leading to injury,clinical examination, investigations, operative

findings, operative procedures and complications during the stay in hospital

and in subsequent follow-up was all recorded on a proforma.

After initial resuscitation, patients were subjected to clinical

examination. Depending on the findings,decision for further investigations like

DPL, radiological studies was made.The decision to operate on the patient is

taken based on the clinical and investigation findings.

With midline laparotomy incision, abdomen is explored from stomach,

duodenum, small intestine and large intestine and solid viscera to find the

pathology and to grade injury according to the organ injury scale.

 The collected data is analyzed and statistics were made according to

need.

Software: Statistical software mainly SPSS11.0 and Systat8.00 was used for

the analysis of the data and Microsoftword and excel have been used to

generate graphs, tables etc.

RESULTS

There were a total of 206 cases of blunt injury to abdomen attended

the emergency ward during the study period.And based on symptoms and

investigations100 patients were admitted in the Department of General

Surgery and the analysis on the patients is as followed.

AGE INCIDENCE
TABLENO:7

Ageinyears OurStudy(%) Devis et al. (%)

<20 4 37
21-30 32 24
31-40 28 15
41-50 26 13
51-60 6 6

61-70 3 3
>70 1 2

Total 100 100

GRAPHNO:1s

40

35

30

25

OUR STUDY
20
DEVIS ET AL

15

10

0
<20 21-30 31-40 41-50 51-60 61-70 >70

In the present study maximum no of cases were in 21-30 years 32(32%)

followed by 31-40 and 41-50 years 28(28%) and 26 (26%) respectively, .and

the mean age was 36.04.

SEX DISTRIBUTION

TABLENO:8

Sex Our Study (%) Davis et al. (%)

Male 62 70

Female 38 30

Total 100 100

GRAPHNO:2:

OUR STUDY DEVIS ET AL

FEMALE
FEMALE 30% MALE,
38% 70%
MALE,
62%

In the present study 62(62% )patients were males and 38(38%) were

females and the male to female ratio was 1.6:1 where as it was 2.3:1 in Davis et

al study and 4...4:1 in other studys like Thripathi et al.the incidence is more in

males as males are more involved in RTA and Assaults.

NATUREOFINJURY

TABLENO:9

Nature of injury Our Study Davis et al (%)

RTA 70 70

Fall from height 18 9

Assault 12 21

Total 100 100

GRAPHNO:3

80

60

40

20

0 DEVIS ET AL
RTA OUR STUDY
FALL FROM
HEIGHT ASSAULT

OUR STUDY
DEVIS ET AL

In this study, most common cause of blunt trauma to abdomen was

Road traffic accidents 70 (70%), second common cause was fall from height in

18 (18%)cases.Other cause was assault in remaining 12(12%) cases and this

is comparable to other studys like Davis et al and Khanna et al series.

LATENT PERIOD

TABLENO:10

Latent period Number Percentage

<2hrs 3 3

2-4hrs 32 32

4-6hrs 38 38

6-8hrs 18 18

8-10hrs 6 6

>10hrs 3 3

Total 100 100

GRAPHNO:4 OUR STUDY
40

35

30

25

20

15

10

0
<2 HRS 2-4 4-6 6-8 8-10 >10
HRS HRS HRS HRS HRS
OUR STUDY 3 32 38 18 6 3

Latent period is the time between occurrence of incident and admission

to hospital. In the present study majority of the patients73 (73%) attended the

hospital within 6 hours after the insult.

ASSOCIATED INJURIES

TABLENO:11

Associated injuries Number Percentage

Chest 16 16

Spine 0 0

Nootherinjuries 84 84

Total 97 100
GRAPHNO:5

OUR STUDY
CHEST SPINE NO OTHER INJURIES

0%

16% 84% 84%

Among the patients with blunt injury to abdomen studied,16(16%)

cases were having associated chest injury with rib fractures. Most of them are

significant and were associated with injury to liver and spleen as they are

under the ribs in the right and left side respectively. In the remaining 84 (84%)

cases there were no significant injuries.

SIGNS & SYMPTOMS

TABLENO:12

Signs &symptoms Number Percentage

Pain 98 98

Hematuria 4 4

Hypotension 18 18

Tenderness 92 92

Rigidity 26 26

Absent bowelsounds 39 39
GRAPHNO:6

OUR STUDY
100

80

60

40

20

In the present study, the most common symptom of presentation was

pain abdomen seen in 98(98%) cases.18(18%) cases presented with

shock and on laparotomy had significant injury to liver and spleen with

haemo peritoneum.In 26(26%) cases there was guarding and rigidity and on

laparotomy had bowel injury.

Tenderness was noted in 92(92%) cases including both managed by

surgical and conservative group. Hematuria was noted in 4 (4%) cases with

retroperitoneal bleed and with renal involvement. Bowel sounds were absent

in 39(39%) cases due to paralytic ileus due to peritonitis or retro peritoneal

bleed.
 ROLE OF INVESTIGATIONS

TABLENO:13

Investigations Finding Number Percentage

DPA Positive 28 58

Pneumo peritoneum 21 21

Rib fractures 16 16
Xray
Vertebra fracture 0 0

Normal 63 63

Collection 52 52
USG
Normal 48 48

Liver injury 12 12

Spleen injury 16 16
CT
Retroperitoneal hematoma 5 5

Perirenal hematoma 4 4

In the present study cases were subjected for DPA, X ray of chest AP

View ,PA view, erect abdomen and DL spine depending on the presentation.
48 cases were subjected to DPA and in 28(28%)cases showed positive

Result .3 cases of retroperitoneal pathology on laparotomy were negative for

DPA. This shows that DPA is sensitive for intra abdominal pathology and poor

In detecting retro peritoneal lesions.

Air under the diaphragm was noted in22(22%) cases, rib fractures

were seen in 16(16%) cases remaining 57(57%) cases it was normal.

 ROLE OF INVESTIGATIONS

GRAPHNO:7

OUR STUDY

CT PERIRENAL HEMATOMA

CT RETROPERITONEAL HEMATOMA

CT SPLEEN INJURY

CT LIVER INJURY

USG NORMAL

USG COLLETION

X RAY NORMAL

X RAY VERTEBRA FRACRTURE

X RAY RIB FRACTURE

X RAY PNEUMO

DPL POSTIVE

0 10 20 30 40 50 60 70

OUR STUDY

All were subjected to USG and it was noted that 70 (70%) cases had

collection in the peritonealcavity either due to solid organ injury or bowel

perforation,mesentery tears. In 37 cases there was associated injury to solid

organs like liver, spleen, renal contusion and retro peritoneal collection.

Patients with solid organ injury in USG were subjected to CT abdomen

and in 12(12%) cases liver was found to be injured, in16 (16%) spleen was

injured, in 5 (5%) retroperitoneal hematoma was noted and in 4(4%) cases

renal injury was present. The injuries were graded and managed conservatively

and surgically based on the grade.

CASE MANAGEMENT

TABLENO:14

Management Number Percentage

Surgical 42 42

Nonsurgical 55 55

Delayedsurgery 3 3

Total 100 100

GRAPHNO:8

SURGICAL NON SURGICAL DELAYED SURGICAL

All the100 cases in the present study were subjected to investigations

and decision was made on management. So in 42(42%) cases surgery was

performed with in 6 hours after admission.

 In 55(55%) cases conservative management was planned and were

keptfor observation. 3 cases among them were taken for surgery within

12 hours due to development of signs of peritonitis in 2 cases and signs of re

Bleed from spleen in1case.

TIME INTERVAL BETWEEN ADMISSION AND SURGERY

TABLENO:15

Admissiontosurgerytime Number Percentage

1-3hrs 32 71

3-6hrs 10 22

>12hrs 3 7

Total 45 100

In the present study, 44 out of 100 cases were managed surgically. The

time interval between admission and surgery varied from 1-3 hours in 31

(70%) cases and between 3-6 hours in 10(23%) cases.

GRAPHNO:9
 OUR STUDY

35
30
25
20
OUR STUDY
15
10
5
0
1-3 HRS 3-6 HRS >12 HRS

3 cases (7%) were initially managed conservatively and were taken up

for surgery in the following 12 hours as two patients among them developed
symptoms of peritonitis and one developed shock due to continuous bleed

from gradeII splenic injury .Hence the time interval between admission and

surgery was delayed in these cases.

ORGANS INJURED
TABLENO:16

Organsinjured Type Number Percentage

GI,GII 10 10
Spleen
GIII,GIV 6 6
GI,GII 7 7
Liver
GIII,GIV 5 5
Mesentery Tear 5 5
Mesocolon Tear 3 3
Stomach Perforation 3 3
Duodenum Perforation 2 2
Jejunum Perforation 4 4
Ileum Perforation 11 11
Caecum Perforation 1 1
 Colon Perforation 2 2

Perirenal Small 3 3
hematom Large 1 1
a
Small 4 4
Retroperitoneal hematoma
Large 1 1
Normal 32 32
Total 100 100

In the present study spleen was involved in 16 cases GI,and GII is10(10%)

cases and GIII,and GIV in6(6%) cases, Liver was injured in 12 cases GI,GII in

7(7%) cases and GIII, GIV in 5(5%) cases, mesentery tear in 5 (5%) cases,

Mesocolon tear in 3 (3%) cases, gastric perforation3(3%) duodenal perforation

in 2 (2%), jejunal perforation in4 (4%)cases ileal perforation in 11(11%), caecal

perforation 1 (1%) and colon perforation 2(2%) renal contusion in 4(4%)

cases, retroperitoneal haematoma in 5 (5%).In the remaining 32 cases no,

significant injuries noted and were treated conservatively.

ORGANSINJURED

GRAPHNO:10
 OUR STUDY

10
9
8
7
6
5
4
3
2
1
0 OUR STUDY

GRAPHNO:11
 OUR STUDY
OUR STUDY

11

4 3 4
1 2 1 1
 PROCEDURESPERFORMED

TABLE NO:17

Organinjured FINDING PROCEDURE NUMBER

GI,GII Conservative 10
Spleen
GIII,GIV Splenectomy 6
GI,GII Conservative 7
Liver
GIII,GIV Gellfoam 5
Mesentery Tear Repair 5
Mesocolon Tear Repair 3
Primaryclosure 2
Stomach Perforation
GJ 1
Primaryclosure 1
Duodenum Perforation
GJ 1
Primaryclosure 3
Jejunum Perforation
Resection and astamosis 1
Primaryclosure 8
Ileum Perforation Resectionanastamosis 2
Stoma 1
Caecum Perforation R t hemiColectomy 1
Primaryclosure 1
Colon Perforation
Colostomy 1

Perirenal Small Conservative 3

Hematoma Large Washgellfoam 1

Retroperitoneal Small Conservative 4

Hematoma Large Washgellfoam 1

In the present study involvement of spleen was noted in 16 cases with

GI,GII in 10 cases which were managed conservatively and withGIII,GIV in 6

cases splenectomy was done.

64
 Liver was injured in 12 cases with GI,GII in7cases which were

Conservatively managed and with GIII,GIV injury in 6 cases laparotomy was

done and gell foams were applied. And cases with mesenteryt ear in 5, meso

colon tear in 3 were repaired.

2 cases of gastric perforation were managed with primary closure and

In other case gastrojejunostomy was done. Similarly for 1 case of duodenal

Perforation primary closure was done and gastrojejunostomy was done in the

other.

A case of ascending colon perforation was closed primarily and in1

case of transverse colon perforation colostomy was done.

In 3 cases of jejunal perforation primary closure was done and in1

case resection and anastamosis was done. Similarly in 11 cases of ileal

perforation primary closure was done and in 2 cases resection and

anastamosis was done in 1 case ileostomy was performed.

The caecal perforation was managed with right hemiColectomy. 3

cases of renal contusions and 4cases of retro peritoneal hematoma were

managed conservatively.

65
 POSTOPOERATIVECOMPLICATIONS

TABLE NO:18

Complication Number Percentage

Woundinfection 10 23

Burst 3 7

Death 5 11

Normal 26 59

Total 44 100

GRAPHNO:12

WOUND INFECTION BURST ABDOMEN DEATH NORMAL

23%

7%
59%

11%

In the present study, wound infection was the most common

Complication after surgery seen in 10(23%) cases. Burst abdomen was noted

In3(7%) case.There are no other complications like pelvi cabscess,

anastamotic leak.There were 5 deaths noted (11%)

Mortality:

Total 5 patients died in our study. All 5 patients died post operatively out

of 44 patients who were operated Therefore mortality in the present study is

11% out of which 4 (9%) were male patients and 1 (2%)was female patient.

The mortality rate in Di Vincenti et al stydy was 23% Cox et al study reported

maortality of 10% and in Davis et al study it was 13.3%.

Among 5 cases 3 patients died becauses of septicemia and 1 patient

due to ARDS and 1 due to suden cardiac arrest. These results or comparable

to another study by jJolly et al. Which showed 10% mortality in their study with

septicemic shock the most common cause of death.

TABLE NO: 19

Mechanism of Death

TYPE MALE FEMALE TOTAL (%)

Septicemia 2 1 60%

ARDS 1 0 20%

Sudden Cardiac 1 0 20%

Arrest

TOTAL 4 1 100%
GRAPHNO:13

SEPTICEMIA

ARDS

SUDDEN CARDIAC
ARREST

GRAPHNO:14

DAVIS ET AL

COX ET AL

DI VINCENTI ET AL

OUR STUDY

0% 5% 10% 15% 20% 25%

DI VINCENTI ET
OUR STUDY COX ET AL DAVIS ET AL
AL
Column1 11% 23% 10% 13.30%
FIGURENO1:HEMOPERITONEUMONLAPAROTOMY

FIGURENO2:LIVERLACERATION

67
 DISCUSSION

In this clinical study in 100 cases of blunt injury to the abdomen

performed in the department of general surgery in General Hospital

AGEINCIDENCE: Maximum number of cases were in 21-30years 32(32%)

followedby 31-40 and 41-50years 28(28%) and 26 (26%) respectively.This

shows that maximum numbers of patients are in reproductive age group and

working population exposed to work stress and insults.And hence the impact

of injury is maximum in the working population and the injury may affect the

earning capacity and economy of the family.

In study by Richard curie67which showed maximum number of cases in

second decade (35%).Similar observations were also made by ALLEN et al

which showed 28% cases between 20-29 years of age and Williams and
Zollinger10 showed 66% cases between10-30 years of sage.

SEX DISTRIBUTION: About 62(62%) patients were male and 38(38%) were

female and male and female ratio is 1.6:1.This shows that male gender is more

prone for blunt injury due to RTA, fall or hit by object because of their

occupation thanfemales.And females were involved in the assault injury in the

house with minimal trauma. It was same compared to other studies like

Tripathi etal(1991)68reported a ratio of 4.4:1 and.Davis et al aratio of 2.3:1

NATURE OF INJURY In this study, most common cause of blunt trauma to

abdomen was road traffic accidents 70(70%) ,Mohapatraetal66 also

Reported 62% cases of blunt injury abdomen were due to RTA. Another study

68
 FIGURENO3:COMPLETEJEJUNALTRANSACTION

FIGURENO4:ANASTAMOSISFORCOMPLETEJEJUNALTR
ANSACTION

69
by Curieetal67also reported 58.6% cases of blunt injury to abdomen were

due to RTA.Similarly Davis et al reported 70% and Khanna et al 57% due to

RTA. Fall from height was found to be the second common cause in 18 (18%)

cases. Other causes were due to Assault in 12 (12%) cases.

LATENT PERIOD : In the present study majority of the patients73 (73%)

attended the hospital within 6 hours after the insult. This can be explained by

the development of trauma care centres in each place and the transportation

facilities.

The delay in hospital admission in the other cases was due to the fact

that unavailability of resources, difficulty in transportation, poor socio

economic status and delay inr eferral from other primary health canters. Delay

in hospital admission was also reported by other Indian authors as well Tripati
et al68

ASSOCIATED INJURIES: Among the patients with blunt injury to abdomen

studied, 16(16%) cases were having associated chest injury with rib fractures.

Most of them are significant and were associated with injury to liver and

spleen as they are under the ribs in the right and left side respectively.and in

the remaining 84 (84%) cases there are no significant injuries.

SIGNS AND SYMPTOMS: In the present study, the most common symptom

of presentation was pain abdomen seen in 98(98%) cases. And 18(18%)

70
 FIGURENO5:ILEALTEAR(CASE-I)

FIGURENO6:ILEOSTOMYFORILEALTEAR

71
cases presented with shock and on laparotomy had significant injury to liver

and spleen with haemoperitoneum. And in 26(26%) cases there was

guarding and rigidity and onlaparotomy had bowel injury. Tenderness was

noted in92(92%) cases including both managed by surgical and conservative

group.Hematuria was noted in 4(4%) cases with retroperitoneal bleed or with

renal involvement. Bowel sounds were absent in 39(39% ) cases due to

paralytic ileus due to peritonitis or retroperitoneal bleed.

A study by Tripati et al68 also reported pain abdomen in 91% of their

patients.Our study is comparable to study by Tripatietal71 which reported

tenderness as most common sign in 80% of the irpatients and shock in 37.2%

of their patients.

Another study by Mohapatra et al66 also reported tenderness as most

common sign in 70.85% of patients and 13.9% of patients with shock.

DIAGNOSTIC PERITONEAL ASPIRATION: In the present study ,diagnostic

aspiration was done in 100 patients and 57 cases showed positive result. All

these 57cases showed significant intra abdominal injury on laparotomy. But 2

cases which were negative for DPL had significant retroperitoneal pathology.

This shows that it is100% accurate in intraabdominal pathology but poor in

detecting retroperitoneal area lesions. In a study Mohapatra et al showed

diagnostic aspiration to be accurate in 95% cases. Another study by

T.NarsingRao et al 72 showed diagnostic aspiration to be 100% accurate.

INVESTIGATIONS: In the present study cases were subjected for X rays of

chest AP view, PA view, erect abdomen and DL spine. Air under the

diaphragm was noted in 27(27%) cases, rib fractures were seen in 16(16%)

72
 FIGURENO7:SPLENICLACERATION

FIGURENO8:SPLENECTOMYSPECIMEN

73
cases and in remaining 57(57%) cases it was normal. Another study
Mohapatra et al reported accuracy of x-ray erect abdomen to be 100% in
detecting Hollow viscous injuries.

All were subjected to USG and it was noted that 52(52%) cases had

Collection in the peritoneal cavity either due to solid organ injury or bowel

perforation,mesentery tears. In 37 cases there was associated injury to solid

organs like liver, spleen, renal contusion and retro peritoneal collection.

In our study USG was sensitive in detecting solid organ.This is

Comparable to other studies like Soffer Detal (2006) which showed USG to

have 89% accuracy, 77% sensitivity and 97% specificity. But it was not very

helpful in detecting hollow viscous injuries

Patients with solid organ injury in USG were subjected to CT abdomen

And in 12(12%) cases liver was found to be injured, in 16 (16%) spleen was

injured,in 5 (5%) retroperitoneal hematoma was noted and in 4(4%) cases

renal injury was present. The injuries were graded and managed

conservatively and surgically based on the grade.

MANAGEMENT: All the 100 cases in the present study were subjected to

Investigations and decision was made regarding management. In 43(43%)

cases surgery was performed within 6 hours after admission.

In 57(57%) cases conservative management was planned and were

Kept for observation.2 cases among them were taken for surgery with in

12 hours due to development of signs of peritonitis. Hence keeping the

patients with significant injury to abdomen for observation will avoid morbidity

and provide appropriate care within time.

74
 FIGURENO9:ILEALTEAR(CASE-II)

FIGURENO10:RESECTION&ANASTAMOSISFORILEALTEAR

75
 Our reports are comparable to Mohapatra et al who reported 39%

laparotomy rates in their series. Non operative management consisted of

nasogastric aspiration, urine out put measurement, I.V.fluids, analgesics and

antibiotics.

ORGANS INJURED: In our study a total of 28 cases were found to be having

solid organ injury.Out of which 17(61%) were managed conservatively and 11

cases(39%) were managed surgically. All patients in nonoperative group

recovered uneventfully except for one who was operated for delayed rebleed.

Our study shows that 61% of solid organ injuries can be managed non
operatively. A study by Rutledge et al70 also showed that incidence of non

operative management in 48% of both hepatic and splenic injuries. This

disparity may be because of change in the sample size.

In the present study, 45 out of 100 cases were managed surgically. The

time interval between admission and surgery varied from 1-3 hours in28

(62%) cases and between 3-6 hours in 15(33%) cases. This shows the

attention given on the trauma patients in the emergency ward and better

radiological and laboratory facilities. The delay in few cases was due to

resuscitation of patient. The time interval varied from 2-6 hours with mean

interval of 4 hrs.

But in 2cases (5%) which were initially managed conservatively were

taken up for surgery in the following 12 hours as these patients developed

symptoms of peritonitis .Hence the admission to surgery time was delayed in

these cases.

76
 FIGURENO11:ILEALTEAR(CASE-III)

FIGURENO12:PRIMARYCLOSUREFORILEALTEAR

77
 In the present study spleen was involved in 16 casesGI,GIIin10(10%)

Cases and GIII,GIV in6(6%) cases, Liver was injured in 12cases GI,GII in 7

(7%) cases and GIII, GIV in 5 (5%) cases, mesentery tear in 5 (5%) cases,

mesocolon tear in 3 (3%) cases, gastric perforation 3(3%) cases,,duodenal

and colonic perforation 2 (2%) cases each, jejunal perforation 4(4%)

cases,ileal perforation 11 (11%) cases, caecal perforation in 1 (1%) case,

renal contusion in 4(4%) cases, retro peritoneal hematoma was noted in 5

(5%) cases.In the remaining 32 (32%) cases there were no significant injuries

and were kept for observation.

PROCEDURE DONE: In the present study involvement of spleen was noted

In 16 cases with GI,GII in 10 cases which were managed conservatively and

with GIII,GIV in 6 cases splenectomy was done.

Our study is nearly similar to study done by Davis et al which reported

24.7% of cases had splenic injuries, out of which 10.7% were operated and

14% were managed conservatively. Another study by R.Curieetal reported

27.5% of cases had splenic injuries, out of which 15% were operated and

splenorraphy was done in all cases

Liver was injured in 12 cases with GI,GII in 7 cases which were

conservatively managed and with GIII,GIV injury in 5 cases laparotomy was

done and gell foams were applied. Our study is contrast to study by Davis et

al which showed 16.47% of liver injuries, out of which 14% underwent

laprotomy and suturing was done in all cases. Another study by R.Curie et al

showed 20.6% of liver injuries.

78
FIGURENO13:GASTROJEJUNOSTOMYFORGASTRICTEAR

FIGURENO14:MESENTERICHEMATOMA

79
 Our study is comparable to most other studies which showed Hepato

splenal injuries as most commonly injured organs in blunt trauma. A study by

Robert Ratledge et al found spleen to be most commonly injured organ than

liver.

Cases with mesentery tear in 5, meso colon tear in 3 were repaired.

Mesenteric tear was observed in 5% cases, which were operated. Our study

Is comparable to a study done by Davis et al which showed 3.4% cases of

mesenteric tear.

2 cases of gastric perforation were managed with primary closure and

In other case gastro jejunostomy was done. Similarly for 1 case of duodenal

perforation primary closure was done and gastrojejunostomy was done in the

other.

In 4 cases of jejunal perforation primary closure was done and in 1

case resection and anastamosis was done. Similarly in 11cases of ileal

perforation primary closure was done in 8 cases and in 2 cases resection and

anastamosis was done, in 1 case ileostomy was performed.

In our study, injury to small intestine was in 17% and compared to a

Study done by Allen and Curry which showed 35.3% cases. A case of

ascending colon perforation was closed primarily and in 1 case of transverse

colon perforation colostomy was done.

Large bowel injury was observed in 3% cases, which were operated.

Our study is comparable to a study by R.Curie et al which showed 3.44% of

their patients with injury to large bowel. The caecal perforation was managed

80
FIGURENO15:OMENTALTEAR

FIGURENO16:MESENTERICTEA

81
with right hemi colectomy. 3 cases of renal contusions and 4 cases of retro

peritoneal hematoma were managed conservatively.

COMPLICATIONS: In the present study, wound infection was the most

common complication after surgery seen in 9(20%) cases. Burst abdomen

was noted in 2 cases. There are no other complications like pelvic abscess,

anastamotic leak. There were no deaths noted.

Our study is comparable to a study by Jolly et al74 which showed

wound infection in 14% of the cases. Another study by Davis et al showed

wound infection as a complication in 15% of the cases.

In our study, out of 100 cases, there are no deaths. But in study by Jolly
74
et al which showed 10% mortality in their study with septicaemia as the

most common cause of death. Another study by Davis et al showed 15%

mortality with septicaemia was the most common cause of death.

82
 SUMMARY

There were a total of 367cases of blunt injury to abdomen attended

The emergency ward of Govt Gen Hospital,RIMS, Kadapa, during the study

period.And based on symptoms and investigations 100 patients were

admitted in the Department of General Surgery and the analysis on the

patients is as followed.

Out of thse 62% were male and 32% were female.

Road Traffic Accidents were the most common cause of blunt

abdominal trauma noted in 28%.

86% cases were in 21-50 years of age, maximum number of cases

were in the age group of 21-30 years.

100% patients presented with pain abdomen.

Most common sign on admission was tenderness of abdomen elicited

In 92% of cases.

Only 9% of patients were admitted with in > 8 hours of injury.

73% of patients were admitted with in 6 hours after injury.

Diagnostic aspiration is an accurate investigation in intra abdominal

Pathology but poor in detecting retro peritoneal area lesions.

X-ray erect abdomen was most sensitive investigation for hollow

viscous injury.

Most useful investigation for solid organ injuries was ultra sound scan of

abdomen and CT.

83
45% cases were managed surgically and 55% were managed

conservatively.

62% of cases were operated with in 3 hours and 33% of cases between

3-6 hours of admission.

Spleen was the most common solid organ involved.

Small bowel is most commonly injured overall.

Wound infection was most common post operative complication in17%

cases.
84
 CONCLUSION

Road traffic accidents form the most common mode of blunt injury to

abdomen which is on rise due to excessive use and speed of motor vehicals. So

adequate measures should be taken to prevent road traffic accidents by strict action

and traffic norms and citizen education regarding road saftey. Well established

trauma care centers should be established at every area / Taluk hospital and near

highways. Measures for early transport of patients from the accident site to the

trauma centre should be under taken as the delay in transport is directly related to

the increased mortality and mobidity of victims Clinical presentation of the patients is

varied and it poses a therapeutic and diagnostic dilemma for the attending

Surgeon due to wide range of clinical manifestations ranging from no

early physical findings to signs and symptoms of shock.

So ,the Trauma surgeon should rely on his physical findings in

association with use of modalities like x-ray abdomen, USG abdomen and

abdominal paracentesis.

Hollow viscus perforations are relatively easy to diagnose on x-ray.

But solid organ injuries are some times difficult to diagnose due to restricted

Use of modern modalities like CT scan in India.

From our study, we conclude that in hemodynamically stable patients

with solid organ injury conservative management can be tried and non

operative management is associated with less complications and morbidity.

85
86
 CASE SHEET PROFORMA
Clinical study on blunt injury to the abdomen

Name :Age & Sex: Time and date of injury:

Religion: IPNO: Date of admission:
Address: Latent period: Date of operation:
Date of discharge: :Date of death:

A .Presenting Complaints

1.Mode of injury:Fall from height; object contact; RTA; assault

2.Site and nature of injury; Pain, site & character

3.Vomiting bilious/ non bilious/ hematemesis; Bowel& bladder

complaints

B.Past history–DM,HTN,TB,Epilepsy,Previous Surgery,Jaundice etc

C.Personal history:Smoker/Alcoholic/Drug addiction

D.Initial assessment of patient

Pallor Odema Cyanosis Icterus Clubbing Lymphadenopathy

Conscious level Signs & degree of shock Temperature

Pulse rate Respiratory rate Blood pressure

E.Assessment of abdominal injuries

1.Inspection:Distension,Contusions

2.Palpation:Tenderness;Guarding:Rigidity;Renal angle
tenderness

3.Percussion:For free fluid; Liver, splenic&Renal angle dullness

4.Auscultation for bowel sounds

5.Per rectal & Per vaginal examination in female

87
F. Associated injuries of Head & Neck; Spine; Chest & Extremities

G. Associated conditions: Psychosis/ pregnancy/ other medical

Condition

H. Other systems: Cardiovascular; Respiratory; Central nervous &

Musculo skeletal systems

I. Investigations

1.Blood-Hemoglobin;Bleeding & clotting time; Blood grouping&

typing; Urea, Creatinine, Sugar; Liver function test; Serum
amylase & lipase; HIV,HBsAg,HCV

2.Diagnostic peritoneal Aspiration

3.ECG;Urine–albumin,sugar,microscopy

4.X-ray chest PA ,AP view;Erect abdomen

5.Ultrasonography & CT head,Chest & abdomen

J. Pre operative diagnosis

K. Treatment

1.Conservative management & initial management, resuscitation

2.Operativeprocedure Anesthesia Incision operative findings

3.Final diagnosis

4.Follow up

5.Post mortem findings in case of death

88
89
90
 KEYTOMASTERCHART

MR : MALE FO : FEMALE
: ROADTRAFFICACCIDENTFALL AS : CONTACTWITHOBJECT
FRFP
: FROMHEIGHT AN : ASSAULT
-
: RIBFRACTURES +HP : ABSENT
AUD
: PRESENT SLL : NORMAL
FCP
: NEGATIVE LRP : POSITIVE
CPR
: AIRUNDERDIAPHRAGMFLUIDC HNS : HEMOPERITONEUM
HSH
: OLLECTIONPERITONEALCOLL PTS : SPLENICLACERATION
RSS
: ECTIONPERIRENALHEMATOM THL : LIVERLACERATION
HIPG
: ASURGICAL : RETROPERITONEALHEMATOMA
JPT
PCP
: HOURS CPA : NONSURGICAL
RAM
: SPLENICHEMATOMA CPM : PERITONITIS
CTS
: TDP : THERAPEUTICLAPAROTOMY
RGL ILEALPERFORATIONGASTRIC
: GJR : JEJUNALPERFORATION
1°CR PERFORATIONCAECALPERFO
: RATIONRESECTION&ANASTA WEI : TRANSVERSECOLONPERFORATION
HCW
: MOSISMESOCOLONTEARSPLE BDP : ASCENDINGCOLONPERFORATION
ILC
: NECTOMY A : MESENTERICTEAR
: : DUODENALPERFORATION
GELLFOAMAPPLICATIONPRIM
: :
ARYCLOSURE GASTROJEJUNOSTOM
: :
RIGHTHEMICOLECTOMYWOU REPAIR
: :
NDINFECTION WASH
: :
LIVERCONTUSION ENDILEOSTOMY
: :
BURST
: :
DIAGNOSTICPERITONEAL
ASPIRATION

91
 MASTERCHART

LATENT INJURY IN HOURS

ASSOCIATED INJURY

CAUSES FOR DELAY

TYPE OF INJURYT

COMPLICATIONS
MANAGEMENT
HYPOTENSION
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
1 SUDHAKAR 21088 22 M F 4 A P A A P P P - N N N NS NS - NS NS NS

2 KRISHNA NAIK 22533 28 M AS 5 A P A A P P A + AUD HP LH NS NS - LH NS NS

3 OBULESU 24126 36 M R 4 RF P A A P P A + RF HP SH NS NS - NS NS NS

4 LAKSHMI DEVI 24582 16 F F 7 A P A A P P P - N N N NS NS - NS NS NS

5 NARAYANAMMA 24829 26 F R 4 A P A A A P A - N N N NS NS - NS NS NS

6 MASTHAN 25016 18 M R 4 RF P A A A P P - RF N N NS NS - NS NS NS

7 PENCHALAMMA 25672 22 F R 5 A P A A P P P - N HP RPH S 2 - RPH GL A

8 CHENNAIAH 26681 43 M R 12 A P A P P P A + AUD FC N S 3 - GP 1°C A

9 SUBBA REDDY 28521 52 M F 9 A P A P P P A + AUD FC N S 2 - JP 1°C WI

10 RAMACHANDRA 34278 16 M R 1 A P A A A A P - N N N NS NS - NS NS NS

11 ANJANEYULU 34821 31 M AS 4 RF P A A A P P - RF N N NS NS - NS NS NS

Contd….

92
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
12 DURGAMMA 36529 36 F R 7 A P A P P P A + N HP PC S 2 - MCT R A

13 BHARGAVI 36826 26 F R 4 A P A A A P P - N N N NS NS - NS NS NS

14 SUBRAMANYAM 38529 29 M R 5 A P A P P P P - N N N NS NS - NS NS NS

15 SURESH 38530 31 M R 4 A P A A A P P - N N N NS NS - NS NS NS

16 KAVYA 39621 19 F F 7 A P A P P P A + AUD FC N S 4 - JP 1°C A

17 NARSAMMA 39817 42 F R 2 RF P A A A P P - RF N N NS NS - NS NS NS

18 NAGAIAH 216 46 M AS 2 A P A A A P P - N HP RPH NS NS - NS NS NS

19 CHINNAIAH 582 52 M R 4 A P P A A P P - N HP PRH NS NS - NS NS NS

20 THIRUPAL 692 26 M R 1 A P A A A P P - N N N NS NS - NS NS NS

21 ESWARIAH 928 22 M R 1 RF P A A A P P - TF N N NS NS - NS NS NS

22 YESTHERU 1084 36 F R 7 A P A P P P A + N HP PC S 2 - MT R WI

23 RAJESWARUDU 1169 29 M F 9 A P A P P P A + AUD FC N S 4 - IP 1°C A

24 ALIVELU 1432 32 M F 2 A P A A A P P - N N N NS NS - NS NS NS

Contd….

93
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
25 PULAMMA 1827 45 F R 3 A P A A A P P - N N N NS NS - NS NS NS

26 SUBAMMA 2291 52 F AS 2 A P A A A P P - N N N NS NS - NS NS NS

27 MALAIAH 2537 47 M R 2 A P A A A P P - N N N NS NS - NS NS NS

28 BALU NAIK 2817 57 M F 4 A P A A A P P - N N N NS NS - NS NS NS

29 VERABHRAMAIHA 3404 48 M R 3 A P A A A P P - N HP RPH NS NS - RPH NS NS

30 GOPI 3921 25 M R 4 RF P A A A P P - RF N N NS NS - NS NS NS

31 MALESWARY 4682 28 F R 5 A P A A A P A + AUD FC N S 2 - IP 1°C A

32 MAILLAIAH 5291 26 M R 2 A P A A A P P - N N NS NS NS - NS NS NS

33 NARSAMMA 7087 37 F R 4 A P A A A P A + AUD FC N S 4 - JP R A

34 GOPI NAIK 8296 33 M AS 2 A P A A A P P - N N NS NS NS - NS NS NS

35 RAMANAIAH 10623 36 M F 9 A P A P A P A + AUD FC N S 4 - JP PC A

36 PURUSHOTHAM 12529 36 M R 11 A P A P P P A + AUD FC N S 2 - DP GJ A

37 SULOCHANA 14482 32 F R 3 RF P PA A A P A + RF HP SL S 2 - SL SR A

Contd….

94
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
38 JAYALAKSHMI 16507 28 F R 2 A P A A A P P - N HP PRH S 2 - PRH GL A

39 NAGAIAH 18902 61 M R 2 A P A A A A P + AUD FC N S 4 - DP 1°C B

40 KASIMBEE 21623 62 F R 2 RF P A A A P P + RF HP SH S 13 - SL SR A

41 RAMADEVO 22492 26 F R 2 A P A A A P P + N HP LC NS NS - LC NS NS

42 RAMANA 28321 29 M F 7 A A A P P A A + AUD FC N S 3 - IP RA WI

43 MAHABOOB PEER 32656 72 M R 3 A P A A A P P + N HP SH NS NS - NS NS NS

44 NARAYANA 34821 28 M F 4 RF P A A A P P + RF HP SL S R - SL SR A

45 ADEAMMA 42832 36 F R 7 A P A P P P A + AUD FC N S 2 - TCP TC A

46 CHANBASHA 42836 32 M R 4 A P A A A P A + AUD FC N S 2 - IP 1°C A

47 NAGESWARI 532 42 F AS 3 A P A A A P P + N HP SL S 2 - SL SR WI

48 LAKSHUMAIAH 1269 39 M R 2 RF P A A A P P + RF HP SH NS NS - SH NS NS

49 RAJAKUMARI 1432 22 F R 7 A P A P P P A - AUD FC N S 2 - CP RHC A

50 SUBRAMANYAM 2041 47 M AS 3 A P A A A P P + N HP PC S 2 - MCT RA A

Contd….

95
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
51 NARASIMHULU 2892 41 M F 2 A P A A A P P + N HP SH NS NS - SH NS NS

52 NAGAIAH 3817 52 M R 14 A P A P P P A + AUD FC N S 5 - IP STOMA WI

53 PULLAMMA 4286 37 F R 2 A P A A A P P + N HP LL S 2 - LL GL A

54 YESTHERU 4925 35 F R 2 RF P A A A P P - RF N N NS NS - NS NS NS

55 RAMADEVI 5827 28 F R 3 A P A A A P P + N HP SL NS NS - SL NS NS

56 GOPI 5903 29 M F 7 A P A P P P A + AUD FC N S 2 - GP 1°C A

57 SUKUMAR 6876 26 M R 4 A P A A A P P + N HP SL S 4 - SL SR A

58 RAMACHANDRA 8271 31 M R 9 A P A P P P A + AUD FC N S 5 - IP RA A

59 NARAYANA 10621 36 M AS 4 A P A A A P P - N HP PRH NS NS - NS NS NS

60 RAMANAMMA 12835 58 F R 4 A A A A A A P + N HP SH NS NS - NS NS NS

61 VENKATESH 14691 39 M F 7 RF P A A P P A + RF HP LL S 2 - LL GL A

62 BALAKONDAIAH 16427 27 M R 2 A P A A A P P + N HP SH NS NS - SH NS NS

Contd….

96
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
63 VANI 18507 21 F R 5 A P A A A P P + N HP LC NS NS - LC NS NS

64 RAMESG 20681 28 M R 7 A P A P A P A + N FC N S 4 - ACP 1°C A

65 NAGAPRASHANTH 22654 29 M R 2 A P A A A P P + N HP SL NS 2 - SL NS NS

66 RAMYA 24890 27 F R 2 A P A A A P P + N HP LC NS NS - LC NS NS

67 SUBBARAYUDU 30062 42 M F 7 A P A A A P A + AUD FC N S 2 - IP 1°C WI

68 ALLABAKASH 31968 36 M R 9 A P A P P P A + AUD HP LL S 2 - LL GL A

69 GULZARBEGUM 36201 36 F R 4 RF P A A A P P - RF N N NS NS - NS NS NS

70 SUBBARATNA 37071 32 F R 4 A P A A A P A + AUD HP SH NS NS - NS SH NS

71 SANTAIAH 37621 49 M AS 3 A P A A A P P + N HP LL S 4 - LL G A

72 NAGAMUNI 39587 26 M T 2 A P A A A P P - N N N NS NS - NS NS NS

73 RAMANAMMA 40514 39 F R 4 A P A A A P P - N N N NS NS - NS NS NS

74 SUNKAMMA 42905 49 F R 7 A P A A P P A + AUD FC N S 4 - IP 1°C A

75 SUBRAMANYAM 43601 35 M F 2 A P A A A P A - N N N NS NS - NS NS NS

Contd….

97
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
76 RAJAIAH 43927 43 M R 5 A P A A A P A + AUD FC N S 2 - GP GJ A

77 NARASIMHULU 44815 46 M AS 3 A P A A A P P + N HP LL S 2 - LL G A

78 SUNKAMMA 1069 62 F R 2 A P A A A A P - N N N NS NS - NS NS NS

79 SUJATHA 1825 47 F R 7 A P A A P P A + AUD HP LC NS NS - LC NS NS

80 SRINIVASULU 2514 23 M R 2 A P A A A P P - N N N NS NS - NS NS NS

81 ESWARAIAH 2098 41 M F 9 A P A A P P A + AUD HP SL S 2 - SL SR WI

82 BHAGYAMMA 3726 41 F F 7 A P A A A P A + AUD FC N S 2 - IP 1°C A

83 PARVEENBANU 5893 11 F R 5 A P A A A P A + N HP PC S 2 - MT R A

84 SUHASINI 6235 25 F R 7 A P A P P A A + N HP PC S 4 - MT R A

85 RAMANA 6917 28 M R 5 A P A A A P P - N N N NS NS - NS NS NS

86 MAHESH 8027 30 M R 4 A P P A A P P - N N N NS NS - NS NS NS

87 RAMACHANDRA 8291 33 M R 4 A P A A A P P - N N N NS NS - NS NS NS

88 CHINNAPEDDAIAH 8796 50 M AS 5 A P A A A P A + AUD FC N S 2 - IP 1°C WI

89 JYOTHI 10127 31 F R 5 RF P A A A P P + RF HP LC NS NS - LC NS NS

90 VENU GOPAL 10829 21 M R 5 A P A A A P P - N HP RPH NS NS - NS NS NS

Contd….

98
 ASSOCIATED INJURY

CAUSES FOR DELAY

LATENT INJURY IN
TYPE OF INJURYT

COMPLICATIONS
HYPOTENSION

MANAGEMENT
AGE IN YEARS

TENDERNESS

PROCEDURE
HEMATURIA

BS ABSEBT

IAS IN HRS

FINDINGS
RIGIDITY
HOURS

X RAY
NMAE

IP NO
S NO

PAIN

USG
DPA
SEX

CT
91 RAJESWARUDU 12962 47 M F 7 A P A A A P A + N HP LL S 2 - LL G A

92 RAMANA 14176 49 M R 5 A P A A A P A + N HP PC S 2 - MT R A

93 NAGAMMA 14827 48 F R 4 A P A A A P P - N N N NS NS - NS NS NS

94 MUNIREDDY 16927 49 M AS 5 A P A A A P A + AUD FC N S 4 - IP 1°C WI

95 MUNIRATHNAM 18104 39 M R 7 A P P A A P A + N HP PC S 2 - MT R A

96 NADIPAIAH 19527 41 M R 5 A P A A A P P - N HP RPH NS NS - NS NS NS

97 LAKSHUMMA 19821 42 F R 4 RF P A A A P P - RF N N NS NS - NS NS NS

98 SANKARAIAH 22637 37 M R 7 A P A A P P A + N HP PC S 3 - MCT R A

99 MADHAN 24807 31 M F 5 A P A A A P P - N HP RPH NS NS - NS NS NS

100 PENCHALAMMA 26501 38 F R 2 RF P A A A P P - RF N N NS NS - NS NS NS

99
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