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Slide Guide

Chapter 5
Abdominal and Pelvic Trauma

SLIDE 5-1  Title Slide


■■ Introduce the topic and explain to students that, based on their preparation for the
course, a series of questions will be asked throughout the lecture. Their active partici-
pation and responses are expected.
■■ Emphasize that this lecture summarizes the information provided throughout the
course, and that all major components will be covered in depth during individual
lectures, skill stations, and demonstrations.
■■ Because you will use the slide show to emphasize key points, it is important to be
familiar with every slide. Proper sequencing of questions and responses facilitates an
interactive presentation.
■■ Be sure to carefully manage the time allotted for this lecture.

SLIDE 5-2  Chapter Statement

SLIDE 5-3  Case Scenario


■■ The discussion of this case should emphasize the need to rapidly evaluate the
abdomen first for hemorrhage and to discover other injuries that can lead to delayed
mortality and morbidity.
■■ The patient is 35 years old and was involved in a high-speed motor vehicle crash. Vital
signs are: BP 105/80; P 110; RR 18; and GCS score 15. He complains of pain in his
chest, abdomen and pelvis.
■■ The discussion should dispense quickly with ABCs and move on to the abdominal
evaluation.
■■ Elicit from the students the fact that, from the mechanism of injury, history, and in-
spection, there is likely an abdominal injury. Ask how they would begin to evaluate it.

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­2    CHAPTER 5  n  Abdominal and Pelvic Trauma

SLIDE 5-4  Objectives


■■ These objectives relate to the lecture/interactive discussion. There may be additional
objectives related to this topic that will be covered in the skill stations and the initial
assessments. Please refer to the Student Manual for the complete list of objectives
related to this topic.

SLIDE 5-5  External Landmarks


■■ This slide illustrates the three main areas of external abdominal anatomy.
■■ Briefly review each component while relating the potential structures for injury that
exist within each.
■■ The anterior abdomen extends from the 4th intercostal space superiorly (often the
transnipple line in men) to the inguinal ligament and symphysis pubis inferiorly, and
between the anterior axillary lines.
■■ The flank area extends from the 6th intercostal space superior to the iliac wing
inferiorly, and between the anterior and posterior axillary lines.
■■ The back area extends from the tip of the scapula superiorly to the iliac crest (or the
inferior gluteal fold) inferiorly, and between the posterior axillary lines.

SLIDE 5-6 Mechanism of Injury: When should you suspect


abdominal and pelvic injury?
■■ The history and physical exam findings suggesting abdominal and pelvic injury in
blunt, penetrating, and explosion trauma are listed.
CHAPTER 5  n  Slide Guide    3

SLIDE 5-7  Abdominal Injury: Blunt Force Mechanism


■■ What organs are most commonly injured in blunt trauma?
■■ The most commonly injured intraabdominal organs in blunt trauma are: (1) spleen
(40% to 55%), (2) liver (35% to 45%), and bowel (5% to 10%).
■■ As the students list the organs, ask them about the types of blunt force that cause the
injuries: (1) compression: direct blow to liver or blowout of the bowel; (2) crushing:
direct blow to the epigastrium with crushing of the pancreas over the spine; and (3)
shearing: inappropriate location of the lap belt contributing to bowel injury.
■■ Airbag deployment does not preclude injury.
■■ Three-point restraints are better than the use of the lap belt only, and the lap belt is
better than no restraint.
■■ Explain that solid organs bleed, but the patient may be nonoperatively managed
(observed) if the bleeding is slow and spontaneously stops.

SLIDE 5-8  Abdominal Injury: Penetrating Mechanism


■■ How does penetrating force injure?
■■ The radiograph is of a patient who presented with a single, small, round, high-velocity
rifle wound to the left upper quadrant. Three fragments (two large and one small) are
seen at the diaphragm.
■■ Emphasize the difference between stab and gunshot wounds.
■■ Projectile speed, size, cavitation effects, tumbling, ricochet of fragments, secondary
fragments, contaminated debris, etc.

SLIDE 5-9  Explosions


■■ This patient was on his way to work when he was injured by an intentionally placed
explosive device. He was thrown 15 feet, sustaining multiple penetrating fragments
to the limbs, abdomen, and chest. He was treated with ABC care. Evaluation showed
a right pneumothorax from fragments and intraabdominal bleeding from penetrating
fragments.
■■ Emphasize the significance of a combination of mechanisms in blast injury, as well as
the historical facts of the injury event.
­4    CHAPTER 5  n  Abdominal and Pelvic Trauma

SLIDE 5-10 Assessment: How do I determine if there is an


abdominal or pelvic injury?

SLIDE 5-11 Assessment: How do I determine if there is an


abdominal or pelvic injury?
■■ Physical exam should include inspection, auscultation, percussion, and palpation.
■■ After identifying “auscultation,” ask the students where to auscultate and what to
listen for. The answer: all four quadrants for the presence or absence of bowel sounds.
■■ Explain that free intraperitoneal blood or gastrointestinal contents can produce an ileus.
■■ Caution the students that injuries to adjacent structures also can produce an ileus
when an intraabdominal injury does not exist.
■■ After identifying “percussion,” ask the students about subtle signs of peritonitis,
tympanitic sounds, and diffuse dullness. Obvious pain and involuntary guarding are
indicative of rebound, and further maneuvers (e.g., “Does it hurt worse when I push in
or let off?”) are not necessary and only cause the patient undue discomfort.
■■ After the students identify “palpation,” ask them about the significance of involuntary
muscle guarding, rebound tenderness, and the presence of a pregnant uterus.

SLIDE 5-12  Assessment: Factors that compromise the exam


■■ During the discussion on assessment, ask the students what factors can compromise
the abdominal examination. The students should respond with the bulleted items on
the slide.
■■ You may ask the students, “How do associated orthopedic injuries compromise, limit,
or distract from the abdominal examination?”
CHAPTER 5  n  Slide Guide    5

SLIDE 5-13  Adjuncts: Urinary Catheter


■■ Why is a urinary catheter inserted in patients with an abdominal injury?
■■ When and why should you exercise caution when inserting a urinary catheter?
■■ The illustration serves as a graphic reminder to assess for signs of a possible urethral
injury before inserting a urinary catheter, such as perineal and scrotal hematomas,
bleeding from the urethra, and rectal blood on the examiner’s gloved finger.

Photograph courtesy of John A. Weigelt, MD, FACS,


USA.

SLIDE 5-14  Urethral Injury

SLIDE 5-15  Adjuncts: Gastric Tube


■■ Why is a gastric tube inserted for patients with abdominal trauma?
■■ When and why should you be cautious when inserting a gastric tube?

SLIDE 5-16  Adjuncts: Blood and Urine Tests


■■ Emphasize key points related to these items from the text, particularly that an urgent
abdominal exploration should not be delayed for tests once the indication for surgery
is discovered.
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SLIDE 5-17  Adjuncts: X-ray Studies


■■ What x-ray studies should you obtain on the patient who sustained blunt and pen-
etrating abdominal trauma?
■■ Emphasize salient points from the text during the discussion, including differentiating
tests done for hemodynamically normal and abnormal patients with abdominal
trauma.
■■ A normal chest radiograph and a pelvic x-ray showing widening of the pubic symphysis
and a sacroiliac fracture are shown.

SLIDE 5-18  Adjuncts: Contrast Studies


■■ What contrast studies should be obtained and what circumstances dictate whether to
obtain them in patients with abdominal injury?
■■ Emphasize salient points from the text during the discussion.
■■ Emphasize the need for speed to definitive care.

CT scan of renal retroperitoneal hematoma courtesy


of Trauma.org

SLIDE 5-19  Diagnostic studies: Blunt Trauma


■■ Table 5-2

SLIDE 5-20 Diagnostic Studies: Penetrating Trauma—


Hemodynamically Normal Patients
■■ Note the different approaches for lower chest, anterior abdominal, and back/flank stab
wounds.
■■ Describe the relative advantages and disadvantages of each.
CHAPTER 5  n  Slide Guide    7

SLIDE 5-21 Laparotomy: Which patients warrant a laparotomy?

SLIDE 5-22 Laparotomy: Which patients warrant a laparotomy?


■■ Indications for Laparotomy – Blunt Trauma
■■ What are the indications for a laparotomy in the patient who sustained blunt abdomi-
nal trauma?
■■ The indications listed on this slide are commonly used to facilitate the surgeon’s
decision-making process in this regard.
■■ Explain the role of FAST and the use of CT for non-operative management.

SLIDE 5-23  Laparotomy: Which patients warrant a laparotomy?


■■ Indications for Laparotomy – Penetrating Trauma
■■ What are the indications for a laparotomy in the patient who sustained penetrating
abdominal trauma?
■■ Explain that, in individual patients, surgical judgment is required to determine the
timing and need for an operation.
■■ The indications listed on this slide are commonly used to facilitate the surgeon’s
decision-making process in this regard.
■■ Explain the role of a positive FAST as confirmation of the abdomen as a source, as well
as the potential for a negative FAST to be misleading, especially early.
■■ Emphasize the safe approach of early operation for patients with abdominal gunshot
wounds.

SLIDE 5-24  Pelvic Fractures


■■ A 45-year-old male was involved in a motorcycle crash at high speed. He had a pelvic
fracture with disrupted bladder neck (as seen on the urethrography) and multiple
intraabdominal injuries.
■■ A pelvic x-ray with extravasated urethral contrast is shown.
■■ Emphasize the association of pelvic fracture with significant abdominal injury, as well
as the importance of the pelvis as a source of blood loss in hemorrhagic shock.
■■ Be prepared with sheet/wrap on the bed
­8    CHAPTER 5  n  Abdominal and Pelvic Trauma

SLIDE 5-25  Pelvic Fractures: Assessment of Pelvic Fractures


■■ Emphasize that manual manipulation of the pelvis to test for mechanical instability is
performed only once (if at all) and in a step-wise fashion. If at any maneuver, instabil-
ity is demonstrated, no subsequent maneuver is necessary. Repeated testing for pelvic
instability can dislodge clots from coagulated vessels and result in fatal hemorrhage.
■■ Describe other physical exam findings, including leg length discrepancy.
■■ Explain the imperative of performing rectal and vaginal exams in patients with a
known or suspected pelvic fracture.

SLIDE 5-26  Pelvic Fractures: Management of Pelvic Fractures


■■ At the initial evaluation of the patient, a pelvic fracture may cause massive hemor-
rhage and should be considered with “C.” Efforts should be made to control hemor-
rhage with a pelvic wrap while early surgical consultation is obtained.
■■ Describe some of the possible methods of hemorrhage control beyond wrapping and
binding.
■■ Be prepared with sheet/wrap on the bed.

SLIDE 5-27 Pelvic Fractures: Hemodynamically Abnormal Patients


■■ Use this slide to summarize the management of pelvic fractures.
■■ Emphasize the key points of obtaining surgical consultation, binding the pelvis, and
determining if there is gross intraperitoneal blood. Ask the students how this can
usually be determined (a grossly positive DPL [>10 mL]). The use of the FAST exam, if
positive, may be helpful. Computed tomography is not indicated in hemodynamically
abnormal patients.
■■ Ask the students about transferring the patient. Their response should be affirmative if
resources are not available. The students also should relate that orthopedic consulta-
tion is required.
■■ The key understanding is that hemorrhage must be controlled, and it may take a
combination of methods to be successful.

SLIDE 5-28  Pitfalls


■■ What pitfalls should I avoid?
CHAPTER 5  n  Slide Guide    9

SLIDE 5-29  Case Scenario


■■ Revisit the Case Scenario that was presented at the beginning of the slide set to give
students the opportunity to apply what they’ve learned in this lesson.

SLIDE 5-30  Questions


■■ Allow for adequate time for additional questions from the students and further discus-
sion before proceeding to the summary slide.

SLIDE 5-31  Summary


■■ These summary points relate to the lecture/interactive discussion. Please refer to the
Student Manual for the complete Summary related to this topic.
■■ Hemodynamically abnormal patients with multiple blunt injuries should be assessed
for intraabdominal bleeding by performing a FAST or DPL.
■■ A CT scan is indicated in hemodynamically normal patients with tenderness, unevalu-
able abdomen, and pain.
■■ Penetrating wounds in proximity to the abdomen and associated hypotension, perito-
nitis, or eviscertion require emergent laparotomy.
■■ Patients with GSWs that transverse the peritoneal cavity or visceral/vascular area of
the retroperitoneum also require laparotomy.
■■ Asymptomatic patients with flank or back stab wounds that are not obviously superfi-
cial are evaluated by serial physical examinations or contrast-enhanced CT. Exploratory
laparotomy is an acceptable option.