LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(1)

CARLOS MESQUITA

TRAUMA 2010

III CONGRESSO DE TRAUMA DO VALE DO PARAÍBA

SÃO JOSÉ DOS CAMPOS

TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

(2)

HOSPITAIS DA UNIVERSIDADE DE COIMBRA SERVIÇO DE URGÊNCIA REGIÃO CENTRO: ~ 2.400.000 h HUC: ~ 1.800.000 (3/4) > 1.500 camas URGÊNCIA: • Admissões / ano ~ 150.000 > 400 / d • Internamentos / ano = 14.000 – 15.000 > 40 / d • Emergências / ano = 1.400 – 1.500 > 4 / d • Interv. cirúrgicas / ano = 3.500 – 3.600

(3)

HOSPITAIS DA UNIVERSIDADE DE COIMBRA SERVIÇO DE URGÊNCIA

(4)

Doença Interna 120.286 Quedas 8.790 Outros 7.231 Acidentes de Trabalho 4.663 Acidentes de Trânsito 2.209 Intoxicações 1.241 Agressões 1.150 Acidentes Escolares 829 Acidentes Desportivos 434 Total / ano 18075 1241 7231 120286 146833 Total / dia 50 3 20 330 403 12 % 1 % 5 % 82 %

(5)

(6)

(7)

(8)

CM 2010

• Acessory spleens in 14 – 30 % of patients A Splenic hilus

B Along splenic vessels, tail of pancreas C Splenocolic ligament

D Greater omentum, perirenal

E Mesentery

F Presacral

G Adnexal

(9)

The white pulp is lymphatic tissue consisting mainly of lymphocytes around arteries.

The red pulp consists of venous sinuses filled with blood and cords of lymphatic cells, such as lymphocytes and macrophages.

(10)

(11)

Splenic studies to infection after splenectomy performed in infancy King H, Schumaker HB. Ann Surg.1952;136:239-42.

Splenectomy and subsequent mortality in veterans of the 1939–45 war Robinette CD, Fraumeni JF. Lancet 2(July): 127–129, 1977.

Deep venous thrombosis and postsplenectomy thrombocytosis Coon WW, Penner J, Clagett P, Eos N. Arch Surg. 1978;113:429-431.

Effects of splenectomy on serum lipids and experimental atherosclerosis Asai K, Kuzuya M, Naito M, Funaki C, Kuzuya F. Angiology. 1988

Jun;39(6):497-504.

Splenic immunity and atherosclerosis: a glimpse into a novel paradigm? Witztum JL. J Clin Invest. 2002 Mar;109(6):721–724

The effects of splenectomy and splenic auto transplantation on plasma lipid levels

Akan AA, Sengül N, Simşek S, Demirer S. J Invest Surg. 2008 Nov-Dec;21(6):369-72.

Spleen Autotransplantation

Menezes MP, Silveira LF. Dissertation in Medicine . Universidade da Beira Interior, Portugal. 2009

(12)

(13)

EAST practice management guidelines for the

2001 Evaluation of Blunt Abdominal Trauma

2003 Nonoperative Management of Blunt Injury to the Liver and Spleen

Eastern Association for the Surgery of Trauma www.east.org

TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(14)

Evaluation of Blunt Abdominal Trauma

 Injury to intra-abdominal viscera must be excluded  Physical examination has limited utility

 Various diagnostic modalities, selection based on • the clinical stability of the patient

• the ability to obtain a reliable physical examination • the provider’s access to a particular modality

 HEMODYNAMICALLY STABLE patients, main choice between CT or FAST

(with CT in a complementary role)  HEMODYNAMICALLY UNSTABLE patients initially evaluated with FAST or DPL

www.east.org TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(15)

www.east.org

Nonoperative Management (NOM)

of Blunt Injury to the Liver and Spleen

 Treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury

 Associated with a low overall morbidity and mortality

 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

 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: useful adjunct in hemodynamically

stable patients who continues to bleed

www.east.org TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

(16)

Nonoperative treatment of blunt injury to solid

abdominal organs

Velmahos GC, Toutouzas KG, Demetríades D. Arch Surg. 2003;138:844-851

 NOM failure for solid abdominal organ injuries in a prospective study higher than rates reported in retrospective studies

 NOM less likely to fail in liver injuries than in splenic or kidney injuries  NOM to be exercised with caution if

• blood transfusion needed, • fluid identified with FAST

• significant (>300 ml) quantity of blood discovered on CT TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(17)

Nonoperative Management of Splenic Lesions

 Growing in popularity in adults

 Success NOT predictable by: • Grade of injury

• Size of haemoperitoneum on CT TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(18)

Nonoperative Management of Splenic Lesions

 Risk of failure increases with:

• Haemodynamic instability • Vascular blush on contrast CT • Higher injury grades

• Age greater than 55 years • Pre-existing splenic disease

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

CM 2010

(19)

Nonoperative Management of Splenic Lesions

 Delayed “rupture”

• Actually, “contained” rupture or secondary haemorrhage • Many represent delayed diagnosis

• Occurs more commonly in adults • NO rationale for bedrest

• No evidence of efficacy • No data for duration

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(20)

In the child

 NOM is the standard

• Successful in > 90% of cases

 Greater risk of OPSI after splenectomy  Indication for laparotomy

• Ongoing haemodynamic instability • Transfusion > 40 mL/kg body weight • Uncertainty regarding associated injuries  CONSIDER INTERVENTIONAL RADIOLOGY TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

CM 2010

(21)

Angio-embolization

 Indications

• ”contrast blush” on CT • polar injuries

• splenic artery aneurysm  Contraindications

• Haemodynamic instability

• Other actively bleeding injuries requiring surgical intervention TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(22)

A DECISÃO DE NÃO OPERAR:

 Condicionada pela estabilidade do doente • ABCDE

 Condicionada pela pouca fiabilidade do exame clínico • situações de défice neurológico

 Condicionada pelo tipo de trauma • fechado ou penetrante

 Condicionada pelos recursos humanos • experiência e organização da equipa  Condicionada pelos recursos materiais

• LPD-Eco-CT

• LAPAROSCOPIA DIAGNÓSTICA? TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(23)



Não têm valor predictivo de sucesso:

• Grau da lesão

• Volume do hemoperitoneu na TAC



Critérios de exclusão:

• Instabilidade hemodinâmica

• Extravasamento de produto de contraste na TAC

• ANGIOGRAFIA / EMBOLIZAÇÃO? • Idade > 55 anos

• Pré-existência de doença esplénica TRATAMENTO NÃO OPERATÓRIO NO TRAUMA ABDOMINAL

LESÕES ESPLÉNICAS APÓS TRAUMA FECHADO

(24)

Associação Lusitana de Trauma e Emergência Cirúrgica

2005 - 12 - 20