htyrfdg

TRAUMA HEPAR

Soetamto Wibowo

Bagian Bedah FK UNAIR / RSUD Dr Soetomo

Surabaya

DIAGNOSISDIAGNOSISDIAGNOSISDIAGNOSISRiwayat Penyakit :

> Mekanisme Trauma : Trauma Tumpul

Trauma Tembus : Tusuk , Tembak

> Kejadian (waktu)

> Nyeri – Febris

Pemeriksaan Fisik : Manajemen ATLS

Pemeriksaan Penunjang : FAST

DPL

CT Scan + Kontras

Riwayat Penyakit :

> Mekanisme Trauma : Trauma Tumpul

Trauma Tembus : Tusuk , Tembak

> Kejadian (waktu)

> Nyeri – Febris

Pemeriksaan Fisik : Manajemen ATLS

Pemeriksaan Penunjang : FAST

DPL

CT Scan + Kontras

Alur Penanganan Penderita Trauma Tumpul Alur Penanganan Penderita Trauma Tumpul AbdomenAbdomen

BLUNT ABDOMINAL TRAUMA

Peritonitis / Overt Hemoperitoneum ?

Expl. Laparotomy

Hemodinamically Stable

Hemodinamically UnStable

Yes

No

Hemodinamically Stable

Reliable PE ?

Abdominal Tenderness

Multiple Ribs Fracture

Abdominal Wall Contusion

Equivocal Findings

USG / DPL

Free Fluid ?

Admid Serial PE

DPL

USG

CT Scan

Repeat USG

Observation

Repeat DPL

CT Scan

Hollow

Organ

Injury ?

CT Scan

Expl lap

Solid Visceral injury ?

Solid Visceral injury ?

Consider Expl. Lap

Consider Non Operative

Consider Expl. Lap

Yes

Yes

Yes

Yes

Yes

No

No

No

NoNo

Negv

Postv

No

Hemodinamically Unstable

USG DPL

Free Fluid ?

Expl lap

Aspiration of Gross Blood

RBC > 100 K/mm3

WBC > 500/mm3

Particulate matter

Bile

Continue Resuscitation

Evaluate Other Potential Source

Repeate USG

DPL

Continue Resuscitation

Evaluate Other Potential Source

Repeate DPL

YesNo No

Grade Injury Description ICD - 9 AIS 90

I. Hematoma Subcapsular Non expanding, <10 cm surface area 864.01 2

864.11

Laceration Capsular tear, Non bleeding,< 1 cm parenchymal depth 864.02 2

864.12

II. Hematoma Subcapsular Non expanding, 10-50% surface area 864.01 2

Intraparenchymal non expanding < 10 cm in diameter 864.11

LacerationCapsular tear, Active bleeding,1-3 cm parenchymal depth 864.03 2

<10 cm length 864.13

III. Hematoma Subcapsular,>50% surface area or expanding 3

Ruptured subcapsular hematoma with active bleeding

intraparenchymal hematoma > 10 cm or expanding

Laceration > 3 cm parenchymal depth 864.04 3

IV. HematomaRuptured intraparenchymal hematoma with active bleeding 864.04 4

Laceration Parenchymal disruption involving 25-75% hepatic lobe

or 1-3 Coinaud's segment within single lobe 4

V. Laceration Parenchymal disruption involving >75% hepatic lobe 864.14 5

or 1-3 Coinaud's segment within single lobe

Vascular Juxtahepatic venous injuries (ie retroheaptic vena cava / 5

central major veins

VI. Vascular Hepatic avulsion 6

Liver Injury Scale : AAST (Revised Liver Injury Scale : AAST (Revised 1994)1994)

Manajemen Non OperativeManajemen Non Operative

I. Dasar Keputusan

1. Hemodinamik Stabil : Saat Datang atau Rapid Response

Stabil bila : MAP > 80 mmHg, Nadi < 120 x/mt

Transfusi tidak lebih dari 2 unit Whole Blood

Tidak ada tanda-tanda klinis Shock

Produksi urine > 50 cc/jam

2. Hasil CT Scan Abdomen : Grading, Pooling (AAST)

3. Tidak ada gejala Peritonitis secara klinis

4. Tidak ada tanda-tanda Perforasi Organ Berongga, Pancreas, Kandung seni atau Diafragma (CT Scan, Plain Foto Abdomen, DPL)

Manajemen Non OperativeManajemen Non OperativeII. Perawatan di RS

1. Bed Rest dengan NGT, sebaiknya di Ruang Intensif

2. Pemeriksaan Fisik Hb (Hct) @ 6 jam (hari I), @ 12 jam (hari II)

3. Hct < 25% : Transfusi PRC, bila transfusi > 4 unit dalam 72 jam : Laparotomi

4. Realimentasi bila fungsi saluran cerna baik5. CT Scan dapat diulang : 3-5 hari Pasca

Trauma lalu 6 minggu pasca trauma 6. Keluar RS setelah 12 hari

7. Tidak melakukan aktivitas fisik berlebihan & olah raga kontak selama 4-6 bulan.

PEMBEDAHANPEMBEDAHANIndikasi Laparotomi :

1.Hemodinamik tidak stabil

2.Peritonitis Generalisata

3.Perlu Transfusi > 4 unit WB

4.Pada CT Scan abdomen :

> Cairan Bebas dalam abdomen tanpa perlukaan organ padat

> Pooling kontrast dalam parenchym hepar,lien atau intra abdomen

Liver Rupture

Incision

HEMOPERITOEUM WITH INSTABILITY

BIMANUAL COMPRESSION RESUSCITATION

PRINGLE MANEUVER

BLEEDING CONTINUES (CONSIDER RETROHEPATIC IVC OR

HEPATIC VENOUS INJURY

PACK PATIENTT

BLEEDING NOT ARRESTED BLEEDING ARRESTED

LEAVE PACK IN PALCE

PACKING, RAPID ABDOMINAL CLOSURE WITH TOWEL CLIPS,PLANNED RE-EXPLORATION

RE-EXPLORE WHEN HYPOTHERMIA, ACIDOSIS

CORRECTED (18-36 H)REMOVE PACK

BLEEDING RECURSDEFINITIVE REPAIR, MAY

REQUIRE VASCULAR ISOLATION NO BLEEDING

IRRRIGATE, DEBRIDE, CLOSEDSUCTION DRAINAGE, CLOSE

COAGULOPATHY AND OTHER INDICATIONS

FOR PACKING

INTRACAVAL SHUNT(ATRICAVAL OR

SAPHENOCAVAL)

RAPID REPAIR OFLACERATED VENOUS

STRUCTURESS

BLEEDING ARRESTED

FINGER FRACTURES TECHNIQUE TOSITE OF INJURY

REPAIR SEVERED BLOODVESELS AND BILE DUCTS

DEBRIDEMENT OF NONVIABLEHEPATIC PARENCHYME

OMENTAL PACK

NO VASCULAR ISOLATION

VASCULAR ISOLATION

ALGORITHM FOR THE INTRAOPERATIVE MANAGEMENT OF COMPLEX HEPATIC INJURIESALGORITHM FOR THE INTRAOPERATIVE MANAGEMENT OF COMPLEX HEPATIC INJURIES

MANUAL MANUAL COMPRESSIONCOMPRESSION

Liver Rupture

Pringle Pringle ManeuverManeuver

Liver Rupture

HaemostasisHaemostasis

Liver RuptureLiver Rupture

Liver SutureLiver Suture

Liver Rupture

Perihepatic packing for left & right lobes Perihepatic packing for left & right lobes rupturerupture

Liver Rupture

Liver RuptureLiver Rupture

Dividing The Liver LigamentDividing The Liver Ligament

Segmental Anatomy of the Liver : Described by Segmental Anatomy of the Liver : Described by CouinaudCouinaud

Omentum : A living Omentum : A living packpack

Liver Rupture

Atrio Caval ShuntAtrio Caval Shunt

Liver Rupture

Penetrating Liver Trauma

Intraparenchymal Ballon Tamponade

Gunshot

Stabwound through

peritoneum

>>Exp. Laparotomy

Trauma Tumpul

Abdomen

(46)

Ruptur Hepar (27)

Ruptur Lien (19)

MNO (9)

Laparotomi (18)

Sukses (8) : Mortalitas = 0

Gagal (1) : Laparotomi

Mortalitas = 2

MNO (9)

Laparotomi (10)

Sukses (8)

Gagal (1) : Laparotomi

Mortalitas = 0

Trauma Tumpul di Surabaya (2003 – Trauma Tumpul di Surabaya (2003 – 2005)2005)

FactorsNOM Success

NOM Failure

p value

n=116 (%) n=33 (%)

1. FAST Positive Result 26 (22) 20 (61) < 0,01

2. Liver 60 (52) 12 (36) 0,11

3. Spleen 44 (38) 23 (70) < 0,01

4. Renal 27 (23) 6 (18) 0,64

5. Associated Intra Abd 1 (1) 6 (18) <0,01

6. Associated Extra Abd 79 (68) 18 (55) 0,13

7. Amount of fluid on CT (mean+SD) 92 + 154 308 + 396 <0,01

Comparison of patients with succesful vs failed NOM

(Velmahos. Arch Surg 2003 ; 56 : 537-541)

Soetamto (n=46) Velmahos (n=206)

Compare 2003 - 2005 1999 - 2001

Surabaya Los Angeles USA

1. Immediate Operative

Liver 18 (66,7) 17 (24)

Spleen 10 (52,6) 27 (33)

Renal 0 2 (10)

2. NOM Failure

Liver 1 (11,1) 12 (16,7)

Spleen 1 (11,1) 23 (34,3)

Renal 00 6 (18,2)

3. Mortality 2 (4,3) 15 (7)

Comparison of Immediate Operative & NOM Failure : Surabaya & LA

CASE ICASE I

MRS. NS 49 YRSMRS. NS 49 YRS

21.03.200321.03.2003 : CAR TRAFFIC ACCIDENT: CAR TRAFFIC ACCIDENT

HISTORY OF AUTOIMMUNE DISEASE HISTORY OF AUTOIMMUNE DISEASE

AND CORTICOSTEROID THERAPY AND CORTICOSTEROID THERAPY

PEPE : ABDOMINAL PAIN AND RIGIDITY: ABDOMINAL PAIN AND RIGIDITY

BPBP :100/70 :100/70 P 120/MINP 120/MIN TEMP. 37°CTEMP. 37°C

RONTGENTRONTGENT : FRACTURE LEFT RIBS # 4,5,6,7,8: FRACTURE LEFT RIBS # 4,5,6,7,8

PELVIC FRACTUREPELVIC FRACTURE

FAST FAST : FREE FLUID +: FREE FLUID +

MRS. NS 49 YRS MRS. NS 49 YRS LIVER RUPTURELIVER RUPTURE

HB HEMODYNAMIC TRANSFUSSION HB HEMODYNAMIC TRANSFUSSION

(g/dl)(g/dl)

24.03.0324.03.03 8.58.5 STABLE STABLE 3 PRC3 PRC CT SCAN ICT SCAN I

22.03.0322.03.03 6.26.2 STABLE STABLE 3 PRC3 PRC



25-03.0325-03.03 10.310.3 STABLE STABLE --

18.03.0318.03.03 12.012.0 STABLE STABLE --

07-04.0307-04.03 CT SCAN IICT SCAN II

22 Maret 2003

7 April 2003

Mrs.NS, 49 yrs

Mr. KLT, 45 yrs

Spleen Rupture Grd IV

Mr. YY 49 yrs

Spleen Rupture Grd III

JT, Male, 29 yo

4 May 2005 : Traffic accident, car accident

5 May 2005 : 6:00 AM > BP 120/80 mmHg; Hb 11,7 g/dl

FAST : Fluid +

Abdomen CT Scan : Spleen Rupture grade IV

Th/ : Non Operative Management

6:00 PM > Hb 10,0 g/dl

perivesical

paracolica

splenorenal

Morison pouch

FAST

Mr JT,Abdomen CT Scan ( II )

Spleen Rupture Grade IVSpleen Rupture Grade IV

Abdomen CT Scan ( III )

Spleen Rupture Grade IV - NOMSpleen Rupture Grade IV - NOM

Perihepatic Packing

Mr H, 13 yrs

Mr S, 18 yrs

Liver Rupture Grd III - NOMLiver Rupture Grd III - NOM

Ms R, 25 yrs

Liver Rupture Grd IV - NOM

Terima KasihTerima Kasih

htyrfdg

Documents

Transcript of htyrfdg