Abdominal Trauma

1
Abdominal Trauma

• Dr. Roberts

2
Exterior Landmarks

• Anterior Abdomen transnipple line to inguinal
  ligament to symphysis pubis to ant. axillary line
  
• Flank anterior to posterior axillary lines from
  6th intercostal space to iliac crest
• Back posterior axillary line to posterior
  axillary line from the scapular tip to iliac crest

3
Internal Anatomy

• Peritoneal Cavity upper lower parts upper
  diaphragm, liver, spleen, stomach, trans
  colon lower small bowel, ascend/descend/sigmoid
  colon, reproductive organs
• Pelvic Cavity rectum, bladder, iliac vessels,
  reproductive organs
• Retroperitoneal Space aorta, inf vena cava,
  majority of duodenum, pancreas, kidneys, ureters,
  posterior portion of asc/descending colon
• not sampled by DPL

4
Mechanism of Injury Blunt vs. Penetrating

• Blunt forces deform solid hollow organs
  leading to rupture/bleeding/peritonitis
• Shearing forces due to deceleration eg,
  liver/spleen at sights of ligamentous attachment
• Spleen 55 gt Liver 35 gt small bowel 10
• retroperitoneal hematoma 15

5
Mechanism of Injury Blunt vs. Penetrating

• Penetrating stab low-velocity GSW inflict
  trauma by laceration/cutting high-velocity GSW
  also transfer Kinetic Energy leading to
  cavitation/fragmentation
• Stab wounds Liver 40 gt SB 30 gt Diaphragm 20
  gt Colon 15
• GSW SB 50 gt colon 40 gt Liver 30 gt vascular
  structues 25

6
Falls cause which type of injuries?

• They produce hollow visceral injuries more
  commonly, and solid organ injuries less commonly.
• They also produce retroperitoneal injuries
  associated with significant blood loss because
  force is transmitted up the axial skeleton.

7
Death from solid organ injury is due to what?

• Acute Blood Loss

8
What organ is the most commonly injured in blunt
abdominal trauma

• Spleen

9
What is Kehrs 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 peritoneum 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.

10
Are lower rib fractures important?

• Yes! They should heighten clinical suspicion for
  splenic injury.
• Remember that tachycardia, hypotension, and acute
  abdominal tenderness are the primary physical
  findings in abdominal trauma.
• Repeat the abdominal exam frequently. A single
  finding is not specific for the diagnosis.

11
What is the problem with hollow visceral injuries?

• They cause a combination of blood loss and
  peritoneal contamination.

12
What risk do head injuries, distracting injuries,
and intoxicated patients run when they have
abdominal trauma?

• The risk of developing peritonitis due to a bowel
  perf. Peritoneal signs develop over time and this
  is why there is a need for repeat exams.

13
How long does it take for inflammation to develop
after a perf?

• 6-8 hours!

14
Retroperitoneal

• SIP A DUCKSSUPRARENAL GLIIVC
  BRANCHESPPANCREAS HEAD
• AAORTA
• DDUODENUMUURETERSCCISTERNA CHYLI
• KKIDNEYS

15
Assessment

• Hypotension Expedite
• Stable no peritonitis detailed evaluation
• Detailed History
• PE inspect EVERYWHERE Percuss/Palpate
• GSW 90 have significant intraperitoneal injury
• Stab wounds 30 significant intraperitoneal
  injury
• Hypotension with GSW or stabbing with peritonitis
  laparotomy
• Pelvic Stability compress ASIS with caution
• Genitalia blood _at_ meatus or ecchymoses _at_
  scrotum/perineum suggests urethral tear
• Rectum sphincter tone, prostate, blood (Bowel
  Perf)
• Vagina blood?
• Gluteal penetrating injuries 50 incidence of
  intraabdominal injury

16
What are the four modalities you can use to
evaluate the abdomen?

• Plain Films
• FAST
• DPL
• CT scan

17

• Plain films may help find free air or associated
  pelvic fractures.

18
What is DPL? What are the numbers?

• DPL is used as a method of rapidly determining
  the presence of intraperitoneal blood
• DPL is particularly useful if the history and
  abdominal examination of a patient who is
  unstable and has multisystem injuries is either
  unreliable (eg, head injury, alcohol, drug
  intoxication) or equivocal (eg, lower rib
  fractures, pelvic fractures, confounding clinical
  examination).

19
What is DPL? What are the numbers?

• Abdominal exploration always is indicated if
  approximately 10 mL of blood is aspirated upon
  insertion of the peritoneal catheter (grossly
  positive) in the unstable patient.
• If findings are negative, infuse 1 L of
  crystalloid solution (eg, lactated Ringer
  solution) into the peritoneum. Then, allow this
  fluid to drain by gravity, and ensure laboratory
  analysis is performed.

20
What is DPL? What are the numbers?

• Presence of more than 100,000 RBC/mm3 or more
  than 500 WBC/mm3 is considered a positive
  finding.

21
What are DPL contraindications?

• If they are going to surgery (absolute)
• Advanced hepatic dysfunction, severe
  coagulopathies, previous abdominal surgeries,
  gravid uterus (relative)

22
FAST

• Indications
• Change in sensorium (brain injury, ETOH or drug
  intoxication)
• Change in sensation (spinal cord injury)
• Injury to adjacent structures (lower ribs, pelvis
  or lumbar spine)
• Prolonged loss of contact with patient
  anticipated, Lap-belt sign

23
FAST
24
What is the FAST scan, what are its indications?

• Focused Assessment with Sonography in Trauma
• Views
• Perihepatic- Morisons pouch
• Perisplenic
• Pelvis
• Pericardium
• Use for trauma
• Decision point, not diagnosis
• should be fast
• should not get in the way of definitive treatment
  or imaging

25
Images
26
Would you do a FAST scan?
27
What is FAST and the numbers

• FAST can identify free intraperitoneal fluid.
• The sensitivity for solid organ encapsulated
  injury is moderate in most studies.
• Hollow viscus injury rarely is identified
  however, free fluid may be visualized in these
  cases.

28
What is FAST and the numbers?

• FAST evaluation of the abdomen consists of
  visualization of
• 1) The pericardium (from a subxiphoid view),
• 2) The splenorenal and the hepatorenal spaces
  (ie, Morison pouch),
• 3) The paracolic gutters,
• 4) The pouch of Douglas in the pelvis. The
  Morison pouch view has been shown the most
  sensitive, regardless of the etiology of the
  fluid.

29
What is FAST and the numbers?

• Free fluid, generally assumed to be blood in the
  setting of abdominal trauma, appears as a black
  stripe (anechoic).
• Free fluid in a hemodynamically unstable patient
  indicates the need for emergent laparotomy.
• CT scan may further evaluate the stable patient
  with free fluid.
• Sensitivity and specificity of these studies
  range from 85-95.

30
(No Transcript)
31
Scan' em all and let God sort them out...

• Toms Paramedic Photo?

32
Donut of Death?

• CT scan often provides the most detailed images
  of traumatic pathology.
• Transport only hemodynamically stable patients to
  the CT scanner.
• The primary advantage of CT scanning is its high
  specificity and use for guiding nonoperative
  management of solid organ injuries.

33
Disadvantages to CT?

• Drawbacks of CT scanning relate to the need to
  transport the patient from the trauma
  resuscitation area and the additional time
  required to perform CT scanning as compared to
  FAST or DPL.
• The best CT imagery requires both oral and IV
  contrast.

34
Interventions

• Gastric Tube decompress stomach blood
  possible esophagus/stomach injury
• Urinary Catheter caution in unstable pelvic fx
  blood at the meatus, scrotal hematoma perineal
  ecchymoses Retrograde urethrogram

35
Interventions

• Urethrography 8 french catheter secured at
  meatus, then 15-20 mL of undiluted contrast with
  gentle pressure
• Cystography bulb syringe attached to a foley
  cath held 40 cm above the patient 300mL of
  contrast infused until flow stops/patient has
  discomfort AB/oblique/post drainage views
• CT Cystogram a better test

36
Indications for laparotomy (celiotomy if you are
a fancy surgeon)

• Blunt trauma with hypotension clinical evidence
  of bleeding
• Blunt trauma with positive DPL or FAST
• Hypotension with penetrating abdominal wound
• GSW traversing the peritoneal cavity or
  visceral/vascular retroperitoneum
• Evisceration
• Bleeding from stomach, rectum, genitourinary
  tract penetrating trauma
• Presenting peritonitis
• Free air, retroperitoneal air or ruptured
  hemidiaphragm in blunt trauma
• CT demonstrating ruptured GI tract,
  intraperitoneal bladder, renal pedicle injury,
  severe visceral parenchymal injury after trauma

37
Specific Injuries

• Diaphragm
• Usually Lt hemidiaphram
• Elevation or blurring of the hemidiaphragm,
  hemothorax, G tube in chest

38
Specific Injuries

• Usually blunt trauma to the abdomen
• Bloody gastric aspirate or retroperitoneal air
  double contrast CT aids diagnosis

39
Specific Injuries

• Small Bowel
• Blunt trauma / seat belt sign / chance fracture
• CT very sensitive
• Pancreas
• Double contrast CT may miss
• Serum amylase may be normal initially
• Rising amylase or pain mandates repeat CT or
  emergent ERCP

40
Specific Injuries

• Liver Laceration Spleen Laceration

41
What are duodenal injuries most often associated
with?

• With high speed vertical or horizontal
  decelerating trauma.
• Also associated with pancreatic injury. The
  classic case is a blow to the midepigastrium
  steering wheel, or bicycle handlebar.

42
What complication may arise with associated
pancreatic injury?
43
On the abdominal plain film, mottled gas to the
left of the spine is seen and resembles that of
gas and feces in the transverse colon. CT through
the same region shows a large gas collection in
the lesser sac with fluid laterally, compatible
with retroperitoneal abscess.
44
What is this?
45

• Tension gastrothorax complicating acute traumatic
  diaphragmatic rupture.
• Remember that in most cases the only fining on
  CXR is blurring of the diaphragm or an effusion

46
What do we do in the E.R.?

• ABCs
• Two large bore IVs
• O2
• Monitor
• NG tube
• Foley (unless suspect urethral injury)
• Zosyn (3.375 g IV)
• Admit! Unless superficial wounds do not reveal
  significant injury.

47
What are the organs most commonly injured by
penetrating trauma to flank?

• Liver, kidney, colon, duodenum, pancreas

48
Necrotizing fasciitis from gluteal stab missed
rectal injury!