- Email: [email protected]
Abdominal packs: Alternatives available
CLINICAL DECISIONS Section Editor: Colleen Swartz, RN, MSN, CCRN
Abdominal Packs: Alternatives Available
Q
What treatment options are available to help control intra-abdominal hemorrhage associated with blunt trauma?
Trauma patients are evaluated for lifethreatening hemorrhage and the need for immediate surgical hemostasis. If the patient is even moderately stable, liver and spleen injuries are managed with nonoperative approaches. Non–life-threatening hemorrhage can be controlled with interventional angiography used to place coil stents or selectively embolize an arterial bleeder. This approach is also used for large retroperitoneal pelvic hematomas. Generally, it is considered prudent not to surgically open the abdo-men of these types of patients. If the patient is hemodynamically unstable, trauma surgeons will do an exploratory laparotomy and pack the abdomen with multiple 18 by 18 inches (45 by 45 cm), densely packed gauze (laparotomy packs). Once the bleeding is tamponaded, a variety of hemostatic agents can be used to treat specific liver and spleen injuries. An effective product (FloSeal Matrix Hemo-static Sealant, made by Fusion Medical Technologies, Mountain View, Calif) has been used on
A
Colleen Swartz, RN, MSN, CCRN, is a trauma coordinator and chief flight nurse at the University of Kentucky Hospital Emergency Department, Lexington. Please write Jane Wick at [email protected] or Colleen Swartz at colleen.swartz@ mvs.hosp.uky.edu with comments. Int J Trauma Nurs 2002;8:18-20. Copyright © 2002 by the Emergency Nurses Association. 1075-4210/2002/$35.00 + 0 65/1/121669 doi:10.1067/mtn.2002.121669
Figure 1. An open surgical abdomen temporarily covered with a silo dressing. This approach allows intra-abdominal contents to distend and prevents abdominal compartment syndrome. Source: Legacy Emanuel Hospital and Health Center, Portland, Ore. Used with permission.
liver and spleen lacerations. FloSeal is a topical hemostatic sealant that stops bleeding from tissue injury and possibly from arterial bleeding sites. The product consists of specially engineered collagen-derived particles and topical thrombin in a gelatin matrix. Once applied to tissue, the gelatin matrix is absorbed by the body in 6 to 8 weeks. Other options to control bleeding include additional hemostatic agents, such as Avitene sheets (Davol, C. R. Bard, Murray Hill, NJ) or powder, Surgicel (Ethicon, Johnson and Johnson, Somerville, NJ) gelfoam, or thrombin. The argon beam coagulator is used for controlling bleeding from tissue surfaces, as occurs in shearing injuries. The spleen can be wrapped in Vicryl (Ethicon, Johnson and Johnson, Somerville, NJ) mesh. If the bleeding is severe and not controlled by surgical or hemostatic intervention, laparatomy packs are left in place. The number of packs left in is documented on the perioperative record. When the patient returns to the operating room for delayed closure of the abdomen, the surgical staff removes and documents the removal of the sponges used for packing. The packing contributes
18 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 8, NUMBER 1
more volume to distended bowel, which increases intraperitoneal contents. To close the laparotomy incision, a “silo” is created to temporarily hold the extruding abdominal contents (See Figure 1). Silos are made by cutting 3000-cc irrigation bags open and sterilizing for future use. The silo bags can be sewn into place serving as a temporary abdominal wall. Once the IV bag is sewn to the fascia, Jackson Pratt drains are placed and the wound is sealed with an Ioban Steridrape. Two other methods used in place of IV bags are a large piece of prolene mesh or a large piece of silastic sheeting. A newer method to close the abdomen uses a large sterile piece of Prolene mesh that is sewn to the fascia, then covered with a silo made with Ioban Steridrape (3M, St Paul Minn). Nurses who care for trauma patients with abdominal packing should anticipate the need for massive transfusions and the potential for abdominal compartment syndrome. Appendix 1 provides an example of a policy used for abdominal compartment syndrome. Additional pictures of silos and information about damage control surgery can be obtained online at http://www.trauma.org/resus/ DCSacs.html. Jane M. Wick, RN, BSN, IJTN Editorial Board Editor’s Note: Readers are encouraged to respond to Ms Wick at ([email protected]). REFERENCES 1. Biffl WL, Moore EE, Burch JM. Femoral arterial graft failure caused by the secondary abdominal compartment syndrome. J Trauma 2001;50:740-2. 2. Burch JM, Moore EE, Moore FA, Fraciose R. The abdominal compartment syndrome. Surg Clin North Am 1996;76:833-42. 3. Bloomfield GL, Ridings PC, Blocker CR, Marmaroa A, Sugarman HJ. Effects of increased intra-abdominal pressure upon intracranial and cerebral perfusion pressure before and after volume expansion. J Trauma 1996;40:936-41; discussion 941-3. 4. Chen R-J, Fang J-F, Chen M-F. Intra-abdominal pressure monitoring as a guideline in the nonoperative management of blunt hepatic trauma. J Trauma 2001;51:44-50. 5. Nayduch DA, Sullivan K, Reed LR II. Abdominal compartment syndrome. J Trauma Nurs 1997;4:5-11. 6. Offner PJ, de Souza AL, Moore EE, Biffl WL, Franciose RJ, Johnson JL, et al. Avoidance of abdominal compartment syndrome in damage-control laparotomy after trauma. Arch Surg 2001;136:676-80. 7. Watson RA, Howdieshell TR. Abdominal compartment syndrome. South Med J 1998;91:326-32. JANUARY-MARCH 2002
APPENDIX
Clinical Management Policy: Abdominal Compartment Syndrome Purpose. Abdominal compartment syndrome (ACS) is defined as an increase in the confined abdominal space, compressing vessels, nerves, and organs. This compromises the circulation and threatens the function and viability of tissues. It is also known as intra-abdominal hypertension (IAH) or increased intra-abdominal pressure (IAP). The ultimate result is that the volume of abdominal contents exceeds the abdominal cavity capacity, leading to multiple organ system failure. ACS can be fatal if not identified in a timely fashion and treated. Policy: Managing intra-abdominal pressure. 1. Normal IAP is 0 mm Hg. Insidious increases associated with tumor, ascites, and pregnancy are tolerated due to slow stretching of the abdominal wall in accommodation. 2. Classifications a. Mild IAP = 10-20 mm Hg. Minor physiologic effects. b. Moderate IAP = 20-40 mm Hg. Increased potential in adverse effects. c. Severe IAP = ≥40 mm Hg. Serious and possibly irreversible complications. 3. Measuring IAP a. Intra-peritoneal method. b. Transfemoral vena cavae pressure measurements c. Gastric pressure measurements (1) Via nasogastric (NG) or gastric tube (GT) (2) Instill 100 mL of water into NG or GT to stomach (3) Proximal end of open tube is held perpendicular to floor (4) Distance from water level to midaxillary line is taken as IAP in centimeters of water and must convert to millimeters of mercury. d. Fluid bladder measurement. Urinary bladder pressure measurement is a simple and reliable method of quantifying IAP. The highly compliant bladder acts as a passive diaphragm and will accurately reflect IAP. Contraindication: Bladder rupture.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions 19
(1) Supine patient. If the patient is oliguric, instill 50 mL of sterile saline into the Foley catheter using aseptic technique. If the patient produces urine, allow the urine to pool in proximal end of catheter drainage tubing. (2) Hold the drainage tubing at a 90° angle to the patient’s pelvis. The height of the urine column (in centimeters) in the drainage tubing reflects the IAP. The meniscus of saline/ urine should have a small amount of fluctuation with respiration. (3) Using the patient’s symphysis pubis as the zero point, use a ruler/measuring device to determine the height of fluid meniscus in centimeters. Record this value on the flow sheet in centimeters of water. To verify abdominal pressure, gently press on the patient’s abdomen and watch the meniscus rise with the increased IAP. e. Transducer bladder measurement (1) Prepare a pressure transducer set-up and attach to bedside monitor. Connect a sterile 18-gauge needle to the end of the tubing and flush to clear air out of needle hub. “Zero” the transducer to the level of patient’s symphysis pubis. (2) Place the patient in supine position. If the patient is oliguric, instill 50 mL of sterile saline into the Foley catheter using aseptic technique. If the patient produces adequate urine, allow urine to pool in the proximal end of the Foley drainage tubing. Using a chest tube clamp, clamp the urinary tubing just proximal to the meniscus. (3) Swab the Foley injection port with alcohol and insert the needle into the drainage tubing toward the bladder. (The urinary drainage tubing does not need to be at a 90° angle— may rest on the bed.) Note the
20
bladder pressure waveform measured on the monitor screen. The waveform should show respiratory variation and you should be able to elevate the pressure by pushing gently on the abdomen. Record the IAP value on the flow sheet in mm of mercury. Remove the needle from the tubing and discard. Maintain sterility and set-up for this patient’s next measurement. 4. Surgical management a. Decompression of the abdomen is imperative when the IAP is elevated; it is considered elective at 25 mm Hg and mandatory at 40 mm Hg. Only decompression will reverse all or some of the adverse effects of the ACS. b. Recognition of lethal reperfusion syndrome is imperative. Asystole has been identified upon abdominal decompression. c. Patient preparation may be assisted by volume loading, mannitol, and sodium bicarbonate to reverse the anaerobic metabolism by-products washout phenomena. Vasopressors may be used to control/assist with hypotension. d. Temporary abdominal wall closure utilized for skin closure. Fascia underneath is left open and separated. (1) Marlex (2) Silo (3) Intravenous bag closure e. Patients are usually re-explored at 24 to 96 hours after initial decompression. Re-exploration, irrigations, debridement, removal, addition of packing and drains are done as appropriate. Fascial and skin closure as appropriate. The policies, procedures, and protocols contained herein represent guidelines only. Clinical judgment must be exercised for each individual case. Source: Karen Schade RN, TNC, for Legacy Emanuel Hospital and Health Center, Trauma Services. Copyright Legacy Emanuel Hospital and Health Center, Portland, Ore. www.legacy.org. Used with permission.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 8, NUMBER 1
Abdominal Packs: Alternatives Available
Q
What treatment options are available to help control intra-abdominal hemorrhage associated with blunt trauma?
Trauma patients are evaluated for lifethreatening hemorrhage and the need for immediate surgical hemostasis. If the patient is even moderately stable, liver and spleen injuries are managed with nonoperative approaches. Non–life-threatening hemorrhage can be controlled with interventional angiography used to place coil stents or selectively embolize an arterial bleeder. This approach is also used for large retroperitoneal pelvic hematomas. Generally, it is considered prudent not to surgically open the abdo-men of these types of patients. If the patient is hemodynamically unstable, trauma surgeons will do an exploratory laparotomy and pack the abdomen with multiple 18 by 18 inches (45 by 45 cm), densely packed gauze (laparotomy packs). Once the bleeding is tamponaded, a variety of hemostatic agents can be used to treat specific liver and spleen injuries. An effective product (FloSeal Matrix Hemo-static Sealant, made by Fusion Medical Technologies, Mountain View, Calif) has been used on
A
Colleen Swartz, RN, MSN, CCRN, is a trauma coordinator and chief flight nurse at the University of Kentucky Hospital Emergency Department, Lexington. Please write Jane Wick at [email protected] or Colleen Swartz at colleen.swartz@ mvs.hosp.uky.edu with comments. Int J Trauma Nurs 2002;8:18-20. Copyright © 2002 by the Emergency Nurses Association. 1075-4210/2002/$35.00 + 0 65/1/121669 doi:10.1067/mtn.2002.121669
Figure 1. An open surgical abdomen temporarily covered with a silo dressing. This approach allows intra-abdominal contents to distend and prevents abdominal compartment syndrome. Source: Legacy Emanuel Hospital and Health Center, Portland, Ore. Used with permission.
liver and spleen lacerations. FloSeal is a topical hemostatic sealant that stops bleeding from tissue injury and possibly from arterial bleeding sites. The product consists of specially engineered collagen-derived particles and topical thrombin in a gelatin matrix. Once applied to tissue, the gelatin matrix is absorbed by the body in 6 to 8 weeks. Other options to control bleeding include additional hemostatic agents, such as Avitene sheets (Davol, C. R. Bard, Murray Hill, NJ) or powder, Surgicel (Ethicon, Johnson and Johnson, Somerville, NJ) gelfoam, or thrombin. The argon beam coagulator is used for controlling bleeding from tissue surfaces, as occurs in shearing injuries. The spleen can be wrapped in Vicryl (Ethicon, Johnson and Johnson, Somerville, NJ) mesh. If the bleeding is severe and not controlled by surgical or hemostatic intervention, laparatomy packs are left in place. The number of packs left in is documented on the perioperative record. When the patient returns to the operating room for delayed closure of the abdomen, the surgical staff removes and documents the removal of the sponges used for packing. The packing contributes
18 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 8, NUMBER 1
more volume to distended bowel, which increases intraperitoneal contents. To close the laparotomy incision, a “silo” is created to temporarily hold the extruding abdominal contents (See Figure 1). Silos are made by cutting 3000-cc irrigation bags open and sterilizing for future use. The silo bags can be sewn into place serving as a temporary abdominal wall. Once the IV bag is sewn to the fascia, Jackson Pratt drains are placed and the wound is sealed with an Ioban Steridrape. Two other methods used in place of IV bags are a large piece of prolene mesh or a large piece of silastic sheeting. A newer method to close the abdomen uses a large sterile piece of Prolene mesh that is sewn to the fascia, then covered with a silo made with Ioban Steridrape (3M, St Paul Minn). Nurses who care for trauma patients with abdominal packing should anticipate the need for massive transfusions and the potential for abdominal compartment syndrome. Appendix 1 provides an example of a policy used for abdominal compartment syndrome. Additional pictures of silos and information about damage control surgery can be obtained online at http://www.trauma.org/resus/ DCSacs.html. Jane M. Wick, RN, BSN, IJTN Editorial Board Editor’s Note: Readers are encouraged to respond to Ms Wick at ([email protected]). REFERENCES 1. Biffl WL, Moore EE, Burch JM. Femoral arterial graft failure caused by the secondary abdominal compartment syndrome. J Trauma 2001;50:740-2. 2. Burch JM, Moore EE, Moore FA, Fraciose R. The abdominal compartment syndrome. Surg Clin North Am 1996;76:833-42. 3. Bloomfield GL, Ridings PC, Blocker CR, Marmaroa A, Sugarman HJ. Effects of increased intra-abdominal pressure upon intracranial and cerebral perfusion pressure before and after volume expansion. J Trauma 1996;40:936-41; discussion 941-3. 4. Chen R-J, Fang J-F, Chen M-F. Intra-abdominal pressure monitoring as a guideline in the nonoperative management of blunt hepatic trauma. J Trauma 2001;51:44-50. 5. Nayduch DA, Sullivan K, Reed LR II. Abdominal compartment syndrome. J Trauma Nurs 1997;4:5-11. 6. Offner PJ, de Souza AL, Moore EE, Biffl WL, Franciose RJ, Johnson JL, et al. Avoidance of abdominal compartment syndrome in damage-control laparotomy after trauma. Arch Surg 2001;136:676-80. 7. Watson RA, Howdieshell TR. Abdominal compartment syndrome. South Med J 1998;91:326-32. JANUARY-MARCH 2002
APPENDIX
Clinical Management Policy: Abdominal Compartment Syndrome Purpose. Abdominal compartment syndrome (ACS) is defined as an increase in the confined abdominal space, compressing vessels, nerves, and organs. This compromises the circulation and threatens the function and viability of tissues. It is also known as intra-abdominal hypertension (IAH) or increased intra-abdominal pressure (IAP). The ultimate result is that the volume of abdominal contents exceeds the abdominal cavity capacity, leading to multiple organ system failure. ACS can be fatal if not identified in a timely fashion and treated. Policy: Managing intra-abdominal pressure. 1. Normal IAP is 0 mm Hg. Insidious increases associated with tumor, ascites, and pregnancy are tolerated due to slow stretching of the abdominal wall in accommodation. 2. Classifications a. Mild IAP = 10-20 mm Hg. Minor physiologic effects. b. Moderate IAP = 20-40 mm Hg. Increased potential in adverse effects. c. Severe IAP = ≥40 mm Hg. Serious and possibly irreversible complications. 3. Measuring IAP a. Intra-peritoneal method. b. Transfemoral vena cavae pressure measurements c. Gastric pressure measurements (1) Via nasogastric (NG) or gastric tube (GT) (2) Instill 100 mL of water into NG or GT to stomach (3) Proximal end of open tube is held perpendicular to floor (4) Distance from water level to midaxillary line is taken as IAP in centimeters of water and must convert to millimeters of mercury. d. Fluid bladder measurement. Urinary bladder pressure measurement is a simple and reliable method of quantifying IAP. The highly compliant bladder acts as a passive diaphragm and will accurately reflect IAP. Contraindication: Bladder rupture.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions 19
(1) Supine patient. If the patient is oliguric, instill 50 mL of sterile saline into the Foley catheter using aseptic technique. If the patient produces urine, allow the urine to pool in proximal end of catheter drainage tubing. (2) Hold the drainage tubing at a 90° angle to the patient’s pelvis. The height of the urine column (in centimeters) in the drainage tubing reflects the IAP. The meniscus of saline/ urine should have a small amount of fluctuation with respiration. (3) Using the patient’s symphysis pubis as the zero point, use a ruler/measuring device to determine the height of fluid meniscus in centimeters. Record this value on the flow sheet in centimeters of water. To verify abdominal pressure, gently press on the patient’s abdomen and watch the meniscus rise with the increased IAP. e. Transducer bladder measurement (1) Prepare a pressure transducer set-up and attach to bedside monitor. Connect a sterile 18-gauge needle to the end of the tubing and flush to clear air out of needle hub. “Zero” the transducer to the level of patient’s symphysis pubis. (2) Place the patient in supine position. If the patient is oliguric, instill 50 mL of sterile saline into the Foley catheter using aseptic technique. If the patient produces adequate urine, allow urine to pool in the proximal end of the Foley drainage tubing. Using a chest tube clamp, clamp the urinary tubing just proximal to the meniscus. (3) Swab the Foley injection port with alcohol and insert the needle into the drainage tubing toward the bladder. (The urinary drainage tubing does not need to be at a 90° angle— may rest on the bed.) Note the
20
bladder pressure waveform measured on the monitor screen. The waveform should show respiratory variation and you should be able to elevate the pressure by pushing gently on the abdomen. Record the IAP value on the flow sheet in mm of mercury. Remove the needle from the tubing and discard. Maintain sterility and set-up for this patient’s next measurement. 4. Surgical management a. Decompression of the abdomen is imperative when the IAP is elevated; it is considered elective at 25 mm Hg and mandatory at 40 mm Hg. Only decompression will reverse all or some of the adverse effects of the ACS. b. Recognition of lethal reperfusion syndrome is imperative. Asystole has been identified upon abdominal decompression. c. Patient preparation may be assisted by volume loading, mannitol, and sodium bicarbonate to reverse the anaerobic metabolism by-products washout phenomena. Vasopressors may be used to control/assist with hypotension. d. Temporary abdominal wall closure utilized for skin closure. Fascia underneath is left open and separated. (1) Marlex (2) Silo (3) Intravenous bag closure e. Patients are usually re-explored at 24 to 96 hours after initial decompression. Re-exploration, irrigations, debridement, removal, addition of packing and drains are done as appropriate. Fascial and skin closure as appropriate. The policies, procedures, and protocols contained herein represent guidelines only. Clinical judgment must be exercised for each individual case. Source: Karen Schade RN, TNC, for Legacy Emanuel Hospital and Health Center, Trauma Services. Copyright Legacy Emanuel Hospital and Health Center, Portland, Ore. www.legacy.org. Used with permission.
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Clinical Decisions
VOLUME 8, NUMBER 1