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