TRATAMENTO NÃO OPERATÓRIO

LESÕES TRAUMÁTICAS

DE ÓRGÃOS SÓLIDOS ABDOMINAIS

TRATAMENTO NÃO OPERATÓRIO

Ordem dos Médicos

CC de Emergência Médica GT Cirurgia de Emergência

Carlos Mesquita

Coimbra - Portugal

CM – II CCMLP – Bahia 2007

HOSPITAIS DA UNIVERSIDADE DE COIMBRA – HUC SERVIÇO DE URGÊNCIA - SU

CM – II CCMLP – Bahia 2007

B a i x a pr i or i da de

M e d

C i r Or t

Of t + Or l

REGIÃO CENTRO: ~ 2.400.000 habitantes HUC: ~ 1.800.000 (3/4)

> 1.500 camas URGÊNCIA / ano:

• Admissões > 150.000

~ 400 / dia

• Internamentos = 14.000 – 15.000

~ 40 / dia

• Intervenções = 3.500 – 3.600

~ 10 / dia

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M ed Car d

Gas t Nef r

P neu Neur P s i q -

1. 000 2. 000 3. 000 4. 000 5. 000 6. 000 7. 000 8. 000 9. 000

HUC - SU

LESÕES DE ÓRGÃOS SÓLIDOS ABDOMINAIS TRATAMENTO NÃO OPERATÓRIO

EAST practice management guidelines for the

2001 Evaluation of Blunt Abdominal Trauma

2003 Nonoperative Management of Blunt Injury to the Liver and Spleen 2007 Nonoperative Management of Penetrating Abdominal Trauma

Eastern Association for the Surgery of Trauma

www.east.org

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2001

EAST practice management guidelines for The Evaluation of

Blunt Abdominal Trauma (BAT)

Injury to intra-abdominal viscera must be excluded in all victims of BAT Physical examination remains the initial step in diagnosis but has limited utility under select circumstances.

Thus, various diagnostic modalities have evolved to assist the trauma surgeon in the identification of abdominal injuries (…). The specific tests selected are based on

• the clinical stability of the patient

• the ability to obtain a reliable physical examination

• the provider’s access to a particular modality

In hemodynamically stable patients (…) in the absence of a reliable physical examination, the main diagnostic choice is between

CT or FAST (with CT in a complementary role) Hemodynamically unstable patients may be initially evaluated with

FAST or DPL www.east.org

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2003

EAST practice management guidelines for

The Nonoperative Management (NOM) of Blunt Injury to the Liver and Spleen

NOM of blunt adult and pediatric hepatic and splenic injuries is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury.

NOM is associated with a low overall morbidity and mortality and does not result in increases in length of stay, need for blood transfusions, bleeding complications, or visceral associated hollow viscus injuries as compared with operative management

There is no evidence supporting

• routine imaging (CT or US) of the hospitalized, clinically improving, hemodynamically stable patient

• or the practice of keeping the clinically stable patient at bedrest Angiographic embolization is a useful adjunct in

NOM of the hemodynamically stable patients who continues to bleed

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www.east.org

Nonoperative treatment of blunt injury to solid abdominal organs

Velmahos GC, Toutouzas KG, Demetríades D.

Arch Surg. 2003;138:844-851

In a prospective study, the rate of NOM failure for solid abdominal organ injuries is higher than the rates reported in retrospective studies

NOM is less likely to fail in liver injuries than in splenic or kidney injuries.

Use of NOM should be exercised with caution if

• blood transfusion is needed,

• fluid is identified with FAST

• or a significant (>300 ml) quantity of blood is discovered on CT

CM – II CCMLP – Bahia 2007

2007

EAST practice management guidelines for

The Nonoperative Management (NOM) of Penetrating Abdominal Trauma

Prudent judgment should be exercised in deciding to apply NOM of penetrating abdominal trauma in a particular institution. It may not be applicable to medical centers with fewer trauma resources

The recommendations are generally from large academic hospitals with in- house senior level clinicians with extensive experience in trauma, in which careful observation and close monitoring are possible

• These patients need to be examined frequently, preferably by the same surgeon

• Pain medications should be given with caution, if at all

• If a patient should develop abdominal pain or hemodynamic instability, NOM should be abandoned and the patient taken to surgery emergently

www.east.org

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Selective nonoperative management

of penetrating abdominal solid organ injuries

Demetríades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A.

Ann Surg. 2006;244:620-628

In the appropriate trauma center environment, selective nonoperative

management of penetrating abdominal solid organ injuries, especially liver injuries, has a high success rate and a low complication rate

High-grade injuries do not preclude nonoperative management

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A decisão de não operar ^,

evitando a laparotomia desnecessária:

1. Decisão condicionada pela estabilidade do doente

ABCDE 2. Decisão condicionada pela pouca fiabilidade do exame clínico,

nomeadamente em situações de défice neurológico 3. Decisão condicionada pelo tipo de trauma

fechado ou penetrante?

4. Decisão condicionada pelos recursos humanos existente

experiência e organização da equipa cirúrgica 5. Decisão condicionada pelos recursos existentes

LPD-Eco-TAC / LD?

“Em África, depois de Joanesburgo, a próxima TAC está no Cairo!”

(Ken Boffard)

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LESÕES TRAUMÁTICAS DE ÓRGÃOS SÓLIDOS ABDOMINAIS

TRATAMENTO NÃO OPERATÓRIO

CT criteria for staging liver trauma

based on the

AAST liver injury scale

Grade 1 Subcapsular hematoma < 1 cm maximal thickness Capsular avulsion

Superficial parenchymal laceration < 1 cm deep Isolated periportal blood tracking

Grade 2 Parenchymal laceration 1-3 cm deep

Parenchymal / subcapsular hematomas 1-3 cm diameter Grade 3 Parenchymal laceration more than 3 cm deep

Parenchymal / subcapsular hematoma > 3 cm diameter Grade 4 Parenchymal/subcapsular hematoma > 10 cm diameter

Lobar destruction Devascularization Grade 5 Global destruction

Devascularization of the liver Grade 6 Hepatic avulsion

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LESÕES TRAUMÁTICAS DE ÓRGÃOS SÓLIDOS ABDOMINAIS TRATAMENTO NÃO OPERATÓRIO

FÍGADO

Critérios de inclusão:

1. Estabilidade hemodinâmica

2. Ausência de sinais de irritação peritoneal 3. Ausência de lesões associadas na TAC 4. Necessidade limitada de transfusões 5. Extravasamento intraparenquimatoso

de produto de contraste durante a realização de TAC

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AAST spleen injury scale

BAÇO

Não têm valor predictivo de sucesso:

• Grau da lesão

• Volume do hemoperitoneu na TAC Critérios de exclusão:

1. Instabilidade hemodinâmica

2. Extravasamento de produto de contraste na TAC

angiografia / embolização ?

3. Idade > 55 years

4. Pré-existência de doença esplénica

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LESÕES TRAUMÁTICAS DE ÓRGÃOS SÓLIDOS ABDOMINAIS

TRATAMENTO NÃO OPERATÓRIO

BAÇO

ANGIOGRAFIA / EMBOLIZAÇÃO

1. Extravasamento de produto de contraste na TAC 2. Lesões polares

3. Aneurismas da artéria esplénica 4. Lesões penetrantes

5. Inexistência de outras lesões com sangramento activo

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LESÕES TRAUMÁTICAS DE ÓRGÃOS SÓLIDOS ABDOMINAIS

TRATAMENTO NÃO OPERATÓRIO

AAST pancreas injury scale

Grade 1 Haematoma: minor contusion; no duct injury Laceration: superficial; no duct injury

Grade 2 Haematoma: major contusion; no duct injury or tissue loss Laceration: major laceration; no duct injury or tissue loss Grade 3 Laceration: distal transection /

/ parenchymal injury with duct injury Grade 4 Laceration: proximal transection /

/ parenchymal injury involving ampulla Grade 5 Laceration massive disruption of pancreatic head

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LESÕES TRAUMÁTICAS DE ÓRGÃOS SÓLIDOS ABDOMINAIS TRATAMENTO NÃO OPERATÓRIO

PÂNCREAS

Exame Clínico

LPD

Amilasémia

Ecografia

CPRE

RMN

TAC

O doente deve estar estável

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Brestas PS, Karakyklas D, Gardelis J, Tsouroulas M, Drossos C.

JOP J Pancreas (Online). 2006; 7(1):51-55

Sequencial CT evaluation

of isolated non-penetrating pancreatic trauma

AAST kidney injury scale

Grade 1 Contusion: microscopic or gross haematuria; urological studies normal Haematoma: subcapsular, non-expanding without parenchymal laceration Grade 2 Haematoma: non-expanding perirenal haematoma confined

to renal retroperitoneum Laceration: < 1 cm parenchymal depth of renal cortex

without urinary extravasation Grade 3 Laceration: > 1 cm parenchymal depth of renal cortex

without collecting system rupture or urinary extravasation Grade 4 Laceration: parenchymal laceration extending through

renal cortex, medulla and collecting system Vascular main renal artery or vein injury with contained haemorrhage Grade 5 Laceration completely shattered kidney

Vascular Avulsion of renal hilum which devascularizes kidney

CM – II CCMLP – Bahia 2007

LESÕES TRAUMÁTICAS DE ÓRGÃOS SÓLIDOS ABDOMINAIS TRATAMENTO NÃO OPERATÓRIO

RIM

Ex. Clínico Mecanismo da lesão Hematúria

Lesões associadas

- abdomen/pélvis/coluna/costelas Choque sem outra explicação

Excluir Hematomas expansivos Extravasamento major Lesões associadas

- abdomen/pélvis/coluna/costelas Lesões

- com hemorragia persistente - hilares

- com tecido não funcionante ou necrótico - com extravasamento urinário major A ausência destes sinais

não exclui a existência de lesão • TAC com contraste / estadiamento

• PIV alta dose (2ml/kg)

• Ecografia

• Angiografia / lesões de grau 4 – 5

“Stenting” / embolização ?

Lord Moynihan of Leeds (1865-1936)

The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation

“The Barber Surgeon”

Jacobus de Cessolis (séc. XV)

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Associação Lusitana de Trauma e Emergência Cirúrgica

2005 - 12 - 20

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DSTC ^™

• 2003 Porto

• 2005 Porto

• 2006 Porto

• 2006 Coimbra

• 2007 Coimbra

Associação Lusitana de Trauma e Emergência Cirúrgica

TEAM

2000 – 2007

Coimbra, Lisboa, Porto, Covilhã e Viseu (Luanda)

ATLS ^®

100 Cursos

1998 – 2007