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Abdominal Trauma

Emergency Medicine Clerkship

Richard W. Stair, MD, FACEP

Abdominal Trauma
Common site of injury for both blunt and penetrating injuries Rapid, life-threatening bleeding can be hidden in the abdomen Unrecognized abdominal injuries in the multi-system trauma patient

Abdominal Trauma
50% of patients intoxicated with use of alcohol and illicit drugs Comorbid injuries (such as brain, spinal cord) Vast amount of space to hide volume Retroperitoneum difficult to evaluate Initial abdominal exam often normal, and many may be initially asymptomatic

Mechanism of Injuries
Blunt Trauma
compression crush shearing deceleration

Penetrating Trauma
direct injury

History - Blunt vs. Penetrating


Blunt
how fast restraint direction of forces time of injury witness accounts prehospital care

Penetrating
type of weapon number of wounds time of wounds blood loss at scene witness accounts prehospital care

Physical Exam
Inspection for overt injury (contusions, cuts, evisceration, bleeding) Auscultation is actually worth very little Palpation for areas of tenderness Wound exploration in EXPERIENCED HANDS Pelvis, perineum, rectal (part of a finger or tube in every hole)

Management
As always, ABCs Primary survey Secondary survey Access Fluid resuscitation Search for blood loss and stop it

Sources of Bleeding in Abdominal Trauma


Intraperitoneal causes
Liver Spleen Vessels

Extraperitoneal causes
Vessels Kidneys

Second Tier Abdominal Injuries


Bleeders take first priority, but:
May get bowel injuries with contamination Pancreatic injuries with chemical injury Mesenteric hematomas Diaphragm injuries

Initial Evaluation in Blunt Trauma


As always, ABCs Access for fluids, blood products Type and cross most important tube to send Rapid, focused history and physical Prioritize life threats Resuscitation comes before testing

Evaluation of Blunt Injuries


Plain films of the abdomen have virtually no utility in the evaluation Ultrasound (F.A.S.T.) Diagnostic Peritoneal Lavage CT scanning Operating room Others (urethrogram)

FAST Exam
Focused Assessment by Sonography for Trauma Screens for free fluid, presumed to be blood in the trauma setting Decision scheme for positive FAST exam based on clinical scenario

FAST Images
4 views to obtain
RUQ view (fluid in Morrisons pouch) LUQ view (fluid in splenorenal space) Subxyphoid (pericardial fluid) Suprapubic (fluid around bladder)

Some get additional views to look for pneumo or hemothorax!

Treatment Decisions with FAST


Positive FAST + unstable patient
Operating room Negative FAST + unstable patient Continue resus, consider other causes, repeat FAST, DPL, or OR if continues unstable after

Positive FAST + stable patient


CT evaluation Negative FAST + stable patient CT evaluation or observation

DPL
Catheter inserted into abdomen, aspirate If no gross blood, bile or stool, then lavage with liter of saline Contraindications exist In general, positive if:
> 100,000 RBC/mm3 >500 WBC/mm3 Gram stain + for bacteria

CT Scanning
As opposed to FAST exams, CT is a very specific diagnostic study Will visualize retroperitoneum as well as intraperitoneum Must have patient enough to get CT scan

Comparison of Diagnostic Studies


FAST
Cost Invasive Sensitive Specific Repeatable Rapid cheap no yes no yes yes

CT
expensive no yes yes yes no

DPL
cheap yes yes no no yes

Under the knife


Indications to go under the knife
Blunt trauma with positive DPL or unstable patient with positive F.A.S.T. Blunt trauma with recurrent hypotension despite resuscitation Peritoneal signs Penetrating wound with hypotension GSW across peritoneal cavity, visceral retroperitoneum

Under the knife


Indications to go under the knife
GI or GU bleeding from penetrating trauma Evisceration Free air, retroperitoneal air Ruptured diaphragm CT evidence of ruptured GI tract, renal pedicle injury, intraperitoneal bladder rupture, or severe perenchymal injury

Specific Injuries
Diaphragm
left hemidiaphragm more commonly injured elevation on CXR, but may be normal difficult to visualize injuries by other means (including CT, MRI) injuries may be missed for years

Specific Injuries
Duodenum
often in unrestrained drivers, handlebar injuries suspect with history, blood in NGT aspirate, or retroperitoneal air

Specific Injuries
Pancreas
often from direct blow compressing pancreas against vertebral column very difficult to evaluate,even with CT ERCP may be helpful

Specific Injuries
Small bowel
can be from penetration or tearing from compression or deceleration think of injury with seatbelt sign DPL good at detection transluminal injuries, but small bowel bleed little, may be negative F.A.S.T. and CT not good for small bowel

Specific Injuries
Solid organs commonly injured
spleen #1 in blunt liver #2 in blunt, #1 in stabs

Management depends on extent/grading of injury


observation for small subcapsular tears emergent laparotomy for grade IV

Specific Injuries
Kidneys
can be from both blunt and penetrating management also depends on severity/grading

Specific Injuries
Pelvic fractures
numerous blood vessels, may result in massive hemorrhage usually massive forces involved classifications based on forces causing injuries if unstable fracture, must be reduced to control hemorrhage

Specific Injuries
Vascular injuries
aorta, IVC can result in massive hemorrhage much more likely form penetrating injury

Take home points


Stay suspicious despite an initially innocuous exam ABCs of trauma Know limitations of studies Surgeons are definitely your friends when it comes to trauma (irreplaceable)