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Trauma Abdominal Cerrado con el Dr. Raphael Parrado
With Dr. Raphael Parrado
Chapter 4 of 6 · Surgical Management
Operative indications
Indications for Operative Intervention and Transfusion Thresholds
Cued at 14:30 · press play
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What the experts said
Blunt abdominal trauma represents 5% of cases in pediatric trauma
The spleen is the most commonly injured organ in pediatric blunt abdominal trauma, accounting for 40% of cases
Other organs injured include pancreas, kidney, and intestines
Seatbelt sign on inspection is an important finding in pediatric blunt abdominal trauma, associated with pelvic fractures and intra-abdominal injuries
FAST ultrasound is the most commonly implemented imaging study to determine presence or absence of free fluid in the abdomen
Laboratory studies for blunt abdominal trauma include renal panel, hematocrit, amylase, and aminotransferase
Amylase greater than 200 or elevated aminotransferase indicates need for CT imaging
PECARN (Pediatric Emergency Care Applied Research Network) criteria for CT imaging include Glasgow Coma Scale, abdominal examination findings, seatbelt sign, and thoracic trauma
For patients with minor injuries, observation in the emergency department or discharge home with follow-up may be appropriate in absence of other injuries
Non-operative management protocol includes crystalloid fluid limit, serial hemoglobin checks to determine transfusion need
Renal injuries with hematuria can be observed, with monitoring for worsening hematuria as indication for intervention
Grade 3, 4, and 5 solid organ injuries can be observed in many institutions if patient remains hemodynamically stable
Indications for operative intervention include peritonitis, free air, and hemodynamic instability
Transfusion threshold for operative consideration is 40 mL/kg of crystalloid or 40 mL/kg of packed red blood cells
Laparotomy incision extends from inferior border of pubis to xiphoid process
Most common injury grades requiring surgery are grades 4 and 5, though grade 3 may also require intervention
Initial surgical steps include packing anterior and posterior abdomen for hemorrhage control
Hemostatic techniques include use of non-permanent coagulation sutures and large figure-of-eight sutures
Anatomic resection is preferred when patient is hemodynamically stable; non-anatomic resection with stapler may be used for ongoing hemorrhage
Most common procedures performed are splenectomy and bowel resection
For arterial pulsatile bleeding versus diffuse venous bleeding, surgeon should pack and return for re-exploration at 24 hours
Damage control surgery with packing is appropriate when patient is hemodynamically unstable despite resuscitation
Transfusion-related complications include hemodynamic instability and pulmonary edema
Patients require monitoring in ICU to ensure adequate fluid removal without complete depletion
Important complications include peritonitis, infectious complications, and overwhelming post-splenectomy sepsis (OPSS), which can be fatal
Post-splenectomy vaccines are given at 2 weeks after surgery
Follow-up includes monitoring for hematoma or fluid collections