Penetrating Trauma with Retroperitoneal Hematoma

Educational Objectives

The goal of this program is to improve management of penetrating trauma with retroperitoneal hematoma. After hearing and assimilating this program, the clinician will be better able to:

1. Choose between operative and nonoperative management of renal injury.

Summary

Vascular injury: hemorrhage is a major cause of casualties in combat; truncal penetrating trauma is a significant cause of hemorrhage (especially in retroperitoneal vessels)

Case vignette: a man of 48 yr of age presented with a gunshot wound to the epigastrium; the patient was severely obese and hemodynamically stable; the abdomen was soft but tender; computed tomography revealed that the projectile was lodged in the retroperitoneum near the right kidney

Retroperitoneal trauma: Shaftan (1980) classified the retroperitoneum into abdominal (midline), flank, and pelvic areas; Kudsk et al (1982) described 3 zones of the retroperitoneum that harbor different structures and have potentially different management plans; zone 1 — contains the aorta, inferior vena cava, pancreas, duodenum, and renal vessels; hematomas in zone 1 are significant and potentially life-threatening; immediate surgical exploration and repair is warranted; zone 2 — contains the colon, kidneys, and blood vessels; the clinician must consider the type of injury (blunt vs penetrating) when deciding the approach; kidney injuries are a major concern in zone 2 hematomas; less severe cases may be manageable without immediate surgery; zone 3 — located in the lower abdomen and contains major blood vessels (iliac arteries and veins); hematoma in zone 3 is serious; nonsurgical techniques (eg, angiography, packing) may be considered; exploration, irrespective of zones, is warranted in patients with hemodynamic instability

Retroperitoneal hematoma after blunt trauma: Feliciano (1990) advised exploration in the midline because major blood vessels and organs may be injured; for lateral (zone 2) injuries, exploration is not required; do not explore pelvic injuries (zone 3); the severity of bleeding and the specific organ involved must be considered prior to surgical intervention; evidence suggests mortality rate of ≈15% for retroperitoneal hematoma from blunt trauma; pelvic embolization may be performed

Case vignette, continued: proximal duodenal and proximal jejunal injuries were repaired; the patient had a zone 2 hematoma on the right and was hemodynamically stable; adequate retroperitoneal exposure was difficult because of obesity

Penetrating trauma: the American Board of Surgery and the Eastern Association for the Surgery of Trauma recommend exploration of penetrating injuries involving the retroperitoneum (zones 1, 2, and 3); the Mattox maneuver involves medial visceral rotation to improve access to retroperitoneal vessels

Case vignette, continued: the Mattox maneuver revealed a zone 1 or zone 2 hematoma; massive bleeding from the inferior vena cava (IVC) on opening the hematoma was difficult to control; proximal and distal control could not be achieved with direct compression; patient habitus was a barrier to hemorrhage control; the patient died after massive blood transfusion and attempted balloon control; the bullet was lodged at the junction of the left renal vein and the IVC; exploration may have been unnecessary in retrospect because the patient was hemodynamically stable and the injury was a low-pressure venous injury

Nonoperative management (NOM): Mingoli et al (2017) found that NOM of renal injury (including penetrating injury) was associated with lower mortality compared with OM; pediatric renal injuries are managed without surgery; a selective approach to exploring penetrating retroperitoneal hematomas may be considered

Readings

Mingoli A, La Torre M, Migliori E, et al. Operative and nonoperative management for renal trauma: comparison of outcomes. A systematic review and meta-analysis. Ther Clin Risk Manag. 2017;13:1127-1138. Published 2017 Aug 31. doi:10.2147/TCRM.S139194; Petrone P, Magadán Álvarez C, Joseph D, et al. Approach and management of traumatic retroperitoneal injuries. Cir Esp (Engl Ed). 2018;96(5):250-259. doi:10.1016/j.ciresp.2018.02.021; Zhu R, Liu X, Li X, et al. Massive retroperitoneal hematoma caused by intercostal artery bleeding after blunt trauma: a case report. J Cardiothorac Surg. 2024;19(1):248. Published 2024 Apr 18. doi:10.1186/s13019-024-02739-2.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Bansal was recorded at the 2023 San Diego Day of Trauma, held on November 3, 2023, in San Diego, CA, and presented by Scripps Health. For information about upcoming CME activities from this presenter, please visit www.scripps.org/dayoftraumacme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS711604

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.