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  • • Mechanism of injury in blunt trauma is rapid deceleration with noncompliant organs most at risk (kidney, liver, spleen, pancreas)

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Penetrating Injuries

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  • • May cause sepsis if a hollow viscus is penetrated

    • Severe and early shock if major vessel or liver is involved

    • Injuries of the kidney, spleen, or pancreas do not usually bleed massively unless a major vessel is involved

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Blunt Injuries

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  • • Focused Assessment with Sonography for Trauma (FAST) exam is important management tool

    • Nonsurgical therapy used in more than 80% of blunt liver and spleen injuries

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Epidemiology

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  • • 30% of patients with "seatbelt signs" have internal injury

    • 85% of patients with blunt liver injury stabilize with resuscitation alone

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Symptoms and Signs

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  • • 35% of patients with hemoperitoneum may not manifest clinical signs of peritoneal irritation

    • Elevated WBC count and fever appearing several hours later

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  • • Do not obtain CT scan in an unstable patient

    • CT has primary role in defining the location and magnitude of intra-abdominal injuries related to blunt trauma

    • Diagnostic laparoscopy has an important role in cases of penetrating abdominal trauma

    • Exploratory laparotomy has 3 main indications following blunt injury: peritonitis, unexplained hypovolemia, and the presence of other injuries know to be associated with intra-abdominal injuries

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  • • Local wound exploration may rule out peritoneal penetration

    • FAST exam used to identify abnormal collections of blood or fluid and obviates need for diagnostic peritoneal lavage (DPL)

    • CT is noninvasive, qualitative, sensitive, and accurate for the diagnosis of intra-abdominal injury

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Abdominal Wall Injuries

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  • • Caused by blunt trauma are most often due to shear forces that devitalize the subcutaneous tissue and skin; debridement is necessary to avoid serious infection

    • Caused by penetrating trauma, debridement and irrigation may be necessary

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Liver Injuries

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  • • Control hemorrhage at laparotomy

    • Initial techniques to control hemorrhage include manual compression, perihepatic packing, and Pringle maneuver

    • Do not use Pringle maneuver for more than 1 hour

    • Hepatic bleeding can be controlled by suture ligation or clip application

    • Electrocautery or the argon beam coagulator can be used to control bleeding from the raw surface of the liver

    • Microfibrillar collagen or hemostatic thrombin soaked gel foam can be applied to bleeding areas with pressure

    • Fibrin glue can be used to treat superficial and deep liver lacerations

    • If massive blood loss has already occurred at time of surgery, consider packing the liver and reexploring in 24-48 hrs

    • Rarely, selective hepatic artery ligation, resectional debridement, or hepatic lobectomy may be required to control hemorrhage

    • Drains should always be used

    • Decompression of the biliary system is contraindicated

    • Suspect hepatic vein injuries when the Pringle maneuver fails to stop hemorrhage; mortality is very high

    • Nonoperative management ...

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