Evaluation of Patients with Penetrating Injury to Abdominal Organs at K.A.P.V Government Medical College and Annal Gandhi Memorial Government Hospital, Trichy

Devarajani, - (2010) Evaluation of Patients with Penetrating Injury to Abdominal Organs at K.A.P.V Government Medical College and Annal Gandhi Memorial Government Hospital, Trichy. Masters thesis, K.A.P. Viswanatham Government Medical College, Tiruchirappalli.

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Abstract

INTRODUCTION: In general, blunt trauma is associated with multiple widely distributed injuries, whereas in penetrating wounds the damage is localized to the path of the bullet or knife. Evaluation of a patient with penetrating injury is made easier if the surgeon can focus attention on the wound made, the weapon or object which made it, and its effect of injuring the adjacent organs or neuro vascular structures if involved. The most important tool of evaluation in penetrating injury is proper clinical examination of the patient to determine the need for immediate laparotomy, or staged procedure after further evaluation or resuscitation. On physical examination, the most frequent physical signs of intra abdominal injuries after penetrating trauma are hypotension, abdominal distension, peritonitis, evisceration of omentum or small intestine or signs of visceral hemorrhage such as hemetemesis, melena and hematuria. A profoundly hypotensive patient who arrives in the casualty with a massive distended abdomen after a penetrating wound obviously has intra abdominal haemorrhage and needs urgent laparotomy. The same applies to patients who present with severe evisceration of omentum or small intestine after a slashing wound or gunshot injury. Even if subsequent findings reveal no bowel or omental injury, laparotomy is indicated in such cases. In gunshot injuries, on inspection of the trunk and upper thighs any entrance or exit wounds are noted, especially in axilla, gluteal clefts and groin creases, as well as eviscerations of omentum, bowel and significant distension is noted. Signs of obvious peritonitis which include guarding, rigidity etc are indications of immediate exploratory laparotomy. Many patients with low velocity gunshot wounds of the flanks or back, stab wounds of anterior aspect of abdomen or back etc, cannot be adequately evaluated by physical examination alone, since passage of knives or missiles through the abdominal Wall alone will cause some local swelling, tenderness and peritoneal signs, on occasion, which are misleadingly suggestive of true intra abdominal injuries. AIM OF STUDY: 1. To evaluate the common patterns of injury. 2. To analyze the procedures to be done for penetrating injuries and the outcome. 3. To evaluate the effect of penetrating injury to abdominal organs, both intra and retroperitoneal, in relationship to various modes of injury. 4. To evaluate various associated injuries and their influence on the outcome. 5. To evaluate the mode of presentation and the need for immediate resuscitation of victims of penetrating injury. 6. To evaluate the value of available investigating tools for the detection of injury to intra abdominal organs. 7. To evaluate common complications associated with penetrating injuries and their management. MATERIALS & METHODS: In my study I have included fifty patients who presented to the causality as emergencies with penetrating wounds of abdominal organs of various types and sites of wounds. The time interval between sustaining the injury and that of admission and the time between admission and operation has been noted and their significance studied. The various weapons, modes of injury, the site of penetration, the organs injured, and the methodology of surgical treatment have been studied. The Hemodynamic status of the patient at the time of presentation and the resuscitatory methods employed has been discussed. The associated injuries, their role in influencing treatment and the various post operative events and complications have been studied. Overall evaluation of the patients with penetrating injury and its role in the outcome has been studied. Plain X- ray of the abdomen in erect posture was taken in most of the cases except in those in a very bad condition. Radiography of other parts was also taken to find out associated injuries, when present. Wound exploration under local anesthesia was done for almost all the patients, and entry into peritoneal cavity was taken as the main criterion for laparotomy. Routine Biochemical testing for Urea, sugar and HB% estimation was done for all the patients prior to surgery. CONCLUSION: 1. The commonest cause of penetrating injury in our study is stab injury with knife and the next comes the bull gore injuries. This is consistent with other studies conducted in similar semi Urban centers like Vellore. 2. Similar to many large series males are more often affected by penetrating abdominal trauma than females and middle aged persons are the most involved than at either extremes of age. 3. Earlier the resuscitation and laparotomy, the better the results of surgery and better the prognosis. 4. The commonest intra abdominal organs to be injured are the hollow viscera namely small bowel, and stomach, followed by liver injuries. 5. Commonest associated injury in our study was chest injuries followed by forearm and other injuries. Fractures were rare and mainly confined to ribs. 6. Early laparotomy after thorough clinical evaluation and good resuscitation with methodical exploratory techniques is essential for total diagnosis and management of various intra abdominal organ injury, so as not to miss any injury. 7. Investigation such as x-rays and Blood tests are only complementary to clinical examination and wound exploration. 8. The desire to avoid unnecessary laparotomy is laudable. Nevertheless marked morbidity or mortality caused by failure to conduct laparotomy in a timely manner can be a dreaded consequence. When clinical and diagnostic studies are unable to resolve the presence or severity of injuries, laparotomy in often more prudent then expectant observation. 9. Routine use of peri-operative antibiotics reduces the rate of past-operative infection and morbidity. 10. Cases that were discharged with minor complications were 12 (24%). 11. Cases that were discharged with major complications were 3 (6%). 12. Inspite of all above measures about 4 (8%) were death cases. 13. Cases that were discharged were 31(62%) uneventfully. 14. Of the 50 cases 6(12%) were negative laparotomies without any organ or omental or mesenteric injury. 15. Thorough peritoneal wash with normal saline and drainage gives good post-operative results. 16. Morbidity and mortality is more in multiple organ injuries than in isolated organ injury. 17. Unstable hemodynamic status at the time of admission should be taken as a definitive indication for laparotomy since no cases were negative on laparotomy. 18. Lt hypochondrium stab wounds cause the maximum damage to intra abdominal organs. 19. Regarding laparoscopy, We have not started to employ Laparoscopy as an aid to confirmation to non availability of trained personnel.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Penetrating Injury ; Abdominal Organs ; K.A.P.V Government Medical College ; Annal Gandhi Memorial Government Hospital, Trichy.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 03 May 2018 03:19
Last Modified: 03 May 2018 08:08
URI: http://repository-tnmgrmu.ac.in/id/eprint/7406

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