Editing Retroperitoneal bleed


== '''Presentation''' ==

* Seen in around 30% of patients who have a trauma laparotomy
* Can be due to blunt or penetrating trauma
** Blunt trauma - contained haematomas
** Penetrating - free haemorrhage
* FAST scan not useful
** Negative FAST in setting of hypotension/no chest findings should raise suspicion for retroperitoneal bleed

== Zone-based classification ==

* Zone 1
** Centrally, and down as far as aortic bifurcation
** Supramesocolic - suprarenal aorta, coeliac axis, proximal SMA, proximal renal artery
** Inframesocolic - infra-renal IVC or aorta
* Zone 2 - laterally
** Renal artery/vein/kidney
* Zone 3 - inferiorly from bifurcation downwards
** Can be associated with pelvic fractures
** Suggest iliac vessel injury


== Management ==

* If unstable - REBOA (resuscitative endovascular balloon occlusion of the aorta) is an option to temporise
* Penetrating - usually explore, because it's likely a true vascular injury needing repair
** Zone 1 - explore, high risk for vascular injury
** Zone 2 - explore kidneys for active haemorrhage or expanding haematoma. Mobilise colon to rule out retroperitoneal colon injury, explore ureters if in proximity to wound
** Zone 3 - explore, major vascular injury likely
* Blunt - try not to explore unless it's a great vessel injury
** Zone 1 - explore
** Zone 2 - explore expanding haematomas or ones that have failed alternative methods (angioembolisation). If contained and stable, no need to explore.
** Zone 3 - do not explore
* Non-op management - consider angioembolisation for these injuries
** minimal vascular injury
** Grade I through IV renal injuries
** All adrenal injuries
** Minor duodenal and pancreatic injuries


== Exploring a central haematoma ==

* Supramesocolic
** Likely aortic injury
** Should get proximal and distal control before entering
*** Proximal - either supra-coeliac aorta, or left medial visceral rotation then clamp above hiatus - see 'trauma laparotomy' for Mattox manoeuvre
*** Distal - at aortic bifurcation
** Then fix the injury
* Inframesocolic
** Aortic
*** Same as above
** IVC
*** Cattell-Brasch
*** Swab on a stick to directly control the bleeding
*** Babcock's on each side of vein, pull up, apply Satinsky clamp across the injury
*** Suture it closed

== Exploring a zone two haematoma ==

* To isolate and resect the kidney, perform a medial visceral rotation on that side, clamp the vessels, check if it needs to be resected or can be repaired, and proceed

[[Category:Trauma]]