Abdominal Trauma
initial eval thoughts of abdominal trauma patient.
Abdominal injuries must be ID'd/treated aggressively Eg: Don't wait for labs to show elevated LFT's before worrying about liver lac dx not as important as recognizing injury exists and surgery may be necessary Normal initial exam does NOT exclude an injury SERIAL exams! (gcs, pain, vital signs, etc)
Intestinal Injury signs/symptoms
Abdominal pain, fever, and tenderness. Be leery of patients involved with high speed vertical or horizontal decelerating trauma Peritoneal sign are found early and are significant
factors that might compromise abdominal exam
Alcohol and other drugs Injury to brain, spinal cord Injury to ribs, spine, pelvis
consider this in pregnant pt w/ abdominal trauma
As pregnancy advances into the second trimester displacement of internal organs occurs and uterus is growing toward the diaphragm. This can be protective to the organs but dangerous to mother and fetus as the uterus will absorb the majority of trauma. Vitals are often unreliable as normal physiologic changes of pregnancy alter vitals and labs
physical exam for abd. trauma pt that's pregnant
Do an abdominal and pelvic exam Observe for bleeding, can test fluid for pH and ferning Normal radiologic studies are often avoided to prevent fetal radiation but sometimes are required Patients under 20 weeks of gestation should have fetal heart tones/ultrasound Patients greater than 20 weeks gestation should be cleared by OB after biophysical profile/ultrasound and monitoring
diagnostic peritoneal lavage (DPL)
Document bleeding if low BP PRO: Early Dx, all pts can do, very quick, 98% sensitive, detects bowel injury, no transport. CON: invasive, low specificity, wont pick up diaphragm/retroperitoneal injury
examples of penetrating trauma
Gunshot wounds Stab wounds Impalements/ puncture wounds Projectiles from explosions, bombs, etc Kinetic energy transfer Cavitation, tumble
Indications for Laparotomy - Penetrating Trauma
Hemodynamically abnormal Peritonitis Evisceration Positive DPL, FAST, or CT Violation of peritoneum
indications for laparotomy in blunt trauma to abdomen
Hemodynamically abnormal with suspected abdominal injury (DPL / FAST) Free air Diaphragmatic rupture Peritonitis Positive CT
Splenic Rupture
Highly vascular organ=Can result in rapid internal bleeding Signs and symptoms: tachycardia, hypotension, acute abdominal tenderness. Kehr's sign=suggestive of splenic rupture. Rib fractures should increase the index of suspicion. Splenic Rupture: may be treated operatively may be treated nonoperatively with proximal coil embolization via angiography
tx of intestinal injury
Management is with surgery. Mesenteric/bowel injury= small amnt of intraperitoneal fluid. They should be admitted/ watched at a minimum. Large bowel injuries can lead to contamination Broad spectrum antibiotics are required preoperatively
two things you look for in small amount of intraperitoneal bleeding.
Mesenteric injury/bowel injury
what's considered a positive FAST exam?
Need 300mL of blood to get POSITIVE FAST exam. can do serial FAST tests overtime to see if amt of fluid is increasing.
Renal Laceration
Renal contusion 92% Renal lacs in 5% Major lacerations involving the medulla and collecting tubules may require surgery if there is continuing blood loss, loss of function, extensive urinary extravasations, devitalized fragments and renal pedicle injuries Renal hematomas can rapidly expand and cause kidney rupture and hemodynamic instability Renal contusion are manage as outpatients. Have the patient pee -look for blood! If no blood, you don't have to look for significant injury to kidney at this point.
urethral injury exploration
Retrograde urethrogram
Indications for IMMEDIATE LAPAROTOMY
Shock Evisceration Peritonitis Bleeding from the stomach, rectum, or GU tract from penetrating trauma Free air or retroperitoneal air after blunt trauma Rupture of diaphragm CT showing: ruptured GI tract, intraperitoneal bladder injury, renal pedicle injury
intestinal injury- what parts involved?
The small bowel is most often associated with penetrating trauma, but deceleration bucket handle tears of the mesentery are possible The doudenum is in the retroperitonium which makes it difficult to diagnose. Digital Rectal Exam should be performed to determine gross blood to see if = bony prominences associated with pelvic fractures. in women check vagina, too.
Liver Injury
Usually associated with high grade injury Symptoms are similar to splenic injuries. Examples include lower rib fractures.
exploration of uterine injuries
ct scan
what's the best diagnostic tool for any abdominal injury?
ct scan
pneumoperitoneum
free air in the peritoneal cavity, abdominal cavity)
closed diagnostic peritoneal lavage
has fewer complications. The needle inserted below the umbilicus unlike the Open DPL which is above the umbilicus
if GCS less than 8...
intubate!
gun shot wounds have low threshold for
laparotomy
majority of blunt abdominal trauma involves which organs?
liver/spleen
what injury is associated with fractured ribs, transverse vertebral process fractures, flank bruises, and hematuria
renal laceration
extraperitoneal rectal injury exploration
rigid sigmoidography
areas where you can bleed to death from.
scalp, extremities, chest, abdomen
Most commonly injured organ in blunt trauma
spleen!
exploration of pelvic frx
x-ray
gastric injury
Stomach injuries are associated with some blood loss, concomitant mesenteric injury and peritonitis over time(6-8 hrs) Management is based on stability and CT findings Usually require surgery Infection is a big risk factor
CT
Tend not to do CT w/ contrast= b'c if trauma it takes too much time for contrast to run through. In certain cases you would want to give it document organ damage if BP=stable PRO: most specific test for injury. up to 98% accurate. CON: high cost/time. misses diaphragm, bowel, some pancreatic injuries. transport required.
intraperitoneal rectal injury exploration
ct scan w/ rectal contrast
cullen's sign
ecchymosis around umbilical area. indicates intraperitoneal bleed, commonly with ectopic pregancy, pancreatitis, etc.
grey-turner's sign
ecchymosis on flanks, indicates retroperitoneal bleed.
primary goal in abdominal trauma
ensure that patients are stabilized as quickly as possible
e-fast
extended fast. Put it toward apex on either lung and you should see parietal and visceral pleura sliding against each other as patient breaths= no pneumothorax. If they don't slide SUSPECT pneumo. If patient stable get CXR.
common causes of blunt trauma to abdomen
falls from heights (retroperitoneal injuries more common), MVCs, MCCs, pedestrian vs. auto, punching, kicking, sporting activities Compressive, shearing , stretching forces exceed the tolerance limits of the tissue or organ the tissues are disrupted.
FAST
focused assessment with sonography for trauma (FAST) document fluid if low BP PRO: Early Dx, all pts can do, non-invasive, quick, repeatable, up to 97% accurate, no transport. CON: operator dependent, bowel gas/subq air distortion, won't pick up diaphragm, bowel, pancreas injuries
what's optimal test for colonic perforation eval?
A gastrografin enema with fluoroscopy remains the optimal test for evaluating colonic perforation
initial management of abd. trauma pt
ABC's 100% O2, cardiac monitoring and two large bore IV lines For hypotensive pts= Always start with normal saline. If they don't get better - give blood. IV crystalloids. O-negative of type specific prbcs should be considered if more than 3 liters of crystalloids and hypotensive. Labs
ABCDE of emed
ABC= airway, intubate, listen to heart and lungs. Give him fluids. (airway, breathing, circulation) D=disability=before give drugs, make sure they can move all of their extremities. E=expose, take clothes off..warm/cool pt prn
what's the gold standard test to diagnose abdominal trauma?
CT scan Organ specific injury Intra-abdominal or retroperitoneal contrast not usually used b'c takes so much time for it to get through your system
common areas of injury for blunt trauma to abdomen
Common areas of injury involve the transition point between fixed organs and the motile organs (i.e. ligament of treitz) Liver tends to protect bowel from herniation/perforation, so left side is more vulnerable to those things.
diagnostics for stable v. unstable pt
FAST exam is good initial screening exam (user dependant) Unstable patients to OR or DPL CT Scan for hemodynamically stable patients Serial exams and a high degree of clinic suspicion are necessary to evaluate blunt abdominal pain safely
transpelvic vascular injury exploration
FAST scan CT scan
transfusions for women of child bearing age v. everyone else
Females of child bearing age get 0- so they don't 'develop rxn Men get 0+ blood.
bladder injury exploration
Hematuria Cystogram
bullets: direct v. indirect injury
Indirect injury Secondary to injury caused by bone or bullet fragments or from the energy transmission from the bullet Direct Injury Injury from the bullet itself Usually entrance smaller than exit of trajectory wounds EXCEPTION: Close-range shots= can cause bigger whole on entrance than exit Kinetic energy transfer, Cavitation, tumble, fragments, ballistics
kher's sign
Kehr's sign is the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classical symptom of a ruptured spleen.
open diagnostic peritoneal lavage
Open DPL requires more expertise than the closed method Patients with pelvic fractures must have their procedure performed opened and above the pelvis
Immediate physiologic evaluation of the abd. trauma pt should focus on 2 major findings
PERITONITIS: diffuse pain. Major indicator for significant organ damage and emergent imaging or surgery HEMODYNAMIC INSTABILITY: Hypotension, narrow pulse pressure and tachycardia provide evidence of vascular injury and warrant immediate surgical exploration.
Indications for Imaging Studies in abdominal trauma pt
Penetrating trauma Abdominal tenderness or distention Abrasions or contusions Gross hematuria Suspected bleeding/ hemodynamic instability High risk mechanism Unreliable neuro exam/ intoxication Pelvic instability or fractures (high risk for retroperiotneal and pelvic trauma)
CT scan is bad for the following abdominal injuries
Poor detection of hollow viscus, pancreatic and diaphragmatic injury
what areas of abdomen is FAST performed
Preformed in the perisplenic, perihepatic, pelvic and pericardial areas. Perihepatic is most commonly positive with fluid accumulation in Morison's pouch.
physical exam for abdominal trauma pt
Typically addressed in the secondary survey Inspection: abrasions, contusions, lacerations, deformity Auscultation: careful exam advised by ATLS Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding Patient should have no AMS or distracting injuries Can't do a full abdominal exam if patient isn't conscious- they cant tell you about pain!
stab wounds
blade directly injuries tissues as it passes through the body External examination may grossly underestimate degree of internal damage, depth of the wound and it trajectory Low energy Lacerations
can't put a catheter in if...
bleeding from urethra
causes of fetal death
maternal shock (maternal resuscitation is key) -placental abruption - torn away from wall of uterus -penetrating wounds to the fetus -preterm labor or PROM nothing you can do to save child if under 20 wks. if >20wks call OBGYN if abd. trauma.
tx of liver injury in stable. v unstable pt
stable: may be managed non-operatively with selective embolization by angiography unstable : surgery. ERCP with or without biliary stenting can be helpful in decompressing clots from the biliary tree and in treating intraparenchymal hepatic duct injury Nonoperative can be combined with operative methods