Abdominal trauma-- by cuiliqing

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									Abdominal trauma

              PRESENTED BY:
         Dr Louza Alnqodi, R3
                   outlines
• Background
• Clinical assessment of pt with blunt ,
  penetrating abdominal injuries
• Diagnostic tools
• Clinical approach
• Conclusion.
                          R1
• Which of the following does not cause a
  falsely +ve DPL?

*Abdominal wall hematoma
*inadequate homeostasis
*pelvic #
*retroperitoneal injury
                          R1
• Which of the following does not cause a
  falsely +ve DPL?

*Abdominal wall hematoma
*inadequate haemostasis
*pelvic #
 retroperitoneal injury
                           R2
• Criteria for a +ve DPL include all of the
  following except:

*initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low chest
  wound.
*presence of bile, bacteria or meat/vegetable fibers
                          R2
• Criteria for a +ve DPL include all of the
  following except:

initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low chest
   wound.
*presence of bile, bacteria or meat/vegetable fibers
                       R3
During the evaluation of a trauma patient, an
  upright CXR showed gastric bubble shifted to the
  rt .
No free air is present. What is the main concern?

*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury
                      R3
During the evaluation of a trauma patient, an
  upright CXR showed gastric bubble shifted to the
  rt .
No free air is present. What is the main concern?

*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury
                               R4
• All of the following are clinical indicators' for urgent
  laprotomy in pt presenting with abdominal stab
  wounds except which one?

•   *bowel protrusion or evisceration
•   *evidence of diaphragmatic injury
•   *indeterminate local wound exploration
•   Peritoneal irritation on physical examination
•   Significant GI bleeding
                               R4
• All of the following are clinical indicators' for urgent
  laprotomy in pt presenting with abdominal stab
  wounds except which one?

•   *bowel protrusion or evisceration
•   *evidence of diaphragmatic injury
•   *indeterminate local wound exploration
•   Peritoneal irritation on physical examination
•   Significant GI bleeding
                              R5
• A 25 yr old male presents with a stab wound to the
  upper abdomen. Vital signs are stable. The
  abdomen is not distended, soft, non-tender. Bowel
  sounds are present. Upright CXR does not
  demonstrate a Penumothorax or free air under
  diaphragm. What should the next step be?

*evaluation of the peritoneal entry by local wound exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
  instruction.
                             R5
• A 25 yr old male presents with a stab wound to the upper
  abdomen. Vital signs are stable. The abdomen is not
  distended, soft, non-tender. Bowel sounds are present.
  Upright CXR does not demonstrate a Penumothorax or free
  air under diaphragm. What should the next step be?

*evaluation of the peritoneal entry by local wound exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
  instruction.
                 anatomy
Anterior abdomen
flank
Back
intraperitoneal contents
Retroperitoneal space contents
 Pelvic cavity contents
o Anterior abdomen:
  trans-nipple line, , anterior axillary lines, inguinal
  ligaments and symphysis pubis.
o flank:
  anterior and posterior axillary line ;sixth intercostal
  to iliac crest
o Back:
posterior axillary line; tip of scapula to iliac crest
• Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-small
  bowel, sigmoid colon


• Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending
   and descending colons


• Pelvic cavity:
 rectum, bladder, iliac vessels and internal genitalia
                  mechanism
• Blunt trauma:

MVC
Seatbelt injury
fall from ht
crash injury
sport injury

 Penetrating injuries.
Blunt abdominal injuries carry a greater risk of
   morbidity and mortality than peneterating
              abdominal injuries.
• associated with severe trauma to multiple
  intraperitoneal organs and extra-abdominal systems

• altered mental status, intoxication

• Peritoneal signs are often subtle and may be
  obscured by other painful injuries
•
  Up to 20% of patients with hemoperitoneum have
  benign abdominal exams on initial presentation.
              Blunt injury

Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%
 Splenic rupture is the most common visceral injury with blunt
  abdominal trauma. Which of the following statements
  regarding splenic rupture is FALSE?


• CT scan may confirm injury, but should not delay laparotomy
  in unstable patients.
• Twenty percent of patients with left lower rib fractures have
  associated splenic injury.
• Focused Assessment with Sonography for Trauma is useful if
  performed by experienced users.
• Signs of peritonitis (involuntary guarding, rigidity, rebound)
  are nearly always present.
 Splenic rupture is the most common visceral injury with blunt
  abdominal trauma. Which of the following statements
  regarding splenic rupture is FALSE?


• CT scan may confirm injury, but should not delay laparotomy
  in unstable patients.
• Twenty percent of patients with left lower rib fractures have
  associated splenic injury.
• Focused Assessment with Sonography for Trauma is useful if
  performed by experienced users.
• Signs of peritonitis (involuntary guarding, rigidity, rebound)
  are nearly always present.
               Seatbelt injuries
Unrestrained front and rear seat passengers are at
  unequivocally greater risk of intra-abdominal injury
  than their restrained counterparts.

The three-point shoulder-lap belt is the most effective
  restraining system and is associated with the lowest
  incidence of abdominal injuries.

However, abdominal injuries are still ascribed to
  shoulder-lap and lap-belt systems.
                 pathogensis
o compression of bowel between the belt and the
 vertebral column.

o an acute short closed-loop obstruction occurs along
  with perforation secondary to the sudden generation
  of high intraluminal pressures.
Clinically, two symptom patterns emerge.

 ~1/4 of pt develop evidence of a hemoperitoneum secondary
  to mesenteric lacerations.

 In the remainder, the intestinal injury most commonly
  involves the jejunum contusion or perforation.

 Rare cases of acute abdominal aortic dissection with
  incomplete or complete occlusion have also been described,
  and injuries to the lumbar spine are not uncommon.
Penetrating abdominal trauma
               Mechanism



• Stab wound
• gunshot
• Knives are not the sole implement used in stabbings.

• Ice picks, pens, coat hangers, screwdrivers, and broken
  bottles.


• most commonly in the upper quadrants, the left
  more commonly than the right.
                 Stab wound

 multiple in 20% of cases
 involve the chest in up to 10% of cases.
 Most stab wounds do not cause an
  intraperitoneal injury
 the incidence varies with the direction of entry
  into the peritoneal cavity
 The liver, followed by the small bowel, is the
  organ most often damaged by stab wounds.
               Gunshot Wounds

• handguns, rifles, and shotgun


• the degree of injury depends .
 amount of kinetic energy imparted by the bullet to
 the victim
 mass of the bullet and the square of its velocity
 Distance .
Missile velocities :
 low (slower than 1100ft/sec)
medium (1100-2000ft/sec)
high (faster than 2000-2500ft/sec)
• type I wounds: long range (>7 yards) , a penetration
  of subcutaneous tissue and deep fascia only.

• Type II wounds: distance of 3 to 7 yards and may
  create a large number of perforated structures.

• Type III wounds occur at point-blank range (<3 yards)
  and involve a massive destruction of tissue
 multiple organ injuries are sustained, notably
 perforations to bowel .

 greatest for small bowel, followed by the
 colon and then the liver.
                Missiles effects
• Extensive tissue damage
• external contaminants tend to be dragged into the
  wound.
• the closure of the tract immediately after the bullet's
  passage may lead to an underestimation of tissue
  damage.
• high-velocity bullets can fragment internally
• Small bowel injury is the most common injury
  resulting from ___ abdominal trauma.

• penetrating
• blunt
• Small bowel injury is the most common injury
  resulting from ___ abdominal trauma.

• penetrating
• blunt
CLINICAL ASSESSMENT OF PT WITH
      ABDOMINAL TRAUMA .
                           history
• Primary goal is to identify that an injury exists, not necessarily
  making an accurate diagnosis.

• The patient's history may be unobtainable, elusive, or
  temporarily abandoned while resuscitative measures are
  carried out.
• History from prehospital care team or transferring hospital :
  the vital signs, physical assessment, prehospital course, and
  response to therapy should be obtained

• Mechanism of injury is an important factor in developing a
  high index of suspicion; thus a detailed history is helpful if
  available.
•   Details about accident
•   Damage to car
•   Velocity
•   Steering wheel damage
•   Type of seatbelts used
•   Air bags deployed
•    All patients involved in deceleration injuries and
    bicycle injuries should be suspected of having
    intraabdominal injury
In penetrating trauma:
• # of shots or stabs
• Type of weapon
• Distance b/w firearm and victim
                    examination
       Overall, the accuracy of the physical examination
    in patients with blunt abdominal trauma is 55% to
    65%.

       Although the presence of physical findings makes
    intraperitoneal injury more likely, their absence does
    not preclude serious pathology, and none is
    exclusively diagnostic of a specific injury.
• Hypotension in the acute stage results from
  hemorrhage that is most often from a solid visceral
  or vascular injury.
• hypotension with significant multiple blunt trauma
  and is unexplained, one should assume the presence
  of intraperitoneal hemorrhage until it is excluded.
•   In conscious, alert pt, look for:
•   Abdo tenderness,90%
•   Peritoneal irritation
•   Penetrating: wounds (log roll pt)
•   Ecchymosis, Cullen and Gray-Turner signs
• Rectal exam is important; assess for blood and
  palpable bony fragments and position of the
  prostate. High riding prostate suggests posterior
  urethral tears.

• Urethral disruption should be considered when blood
  is noted at the meatus.

• Vaginal exam for bleeding – may suggest bony
  fragments causing laceration. Implications of
  bleeding during pregnancy should be considered.
• The major findings with injury of the solid
  abdominal organs are those of hemorrhagic shock.
  Signs with solid organ injury include all of the
  following EXCEPT:

•    abdominal pain and tenderness
•    early bacterial peritonitis
•    development of rebound, guarding and rigidity
•    hypotension and tachycardia
•    palpable mass and radiographic mass effect (may result from
    confined hemorrhage)
• The major findings with injury of the solid
  abdominal organs are those of hemorrhagic shock.
  Signs with solid organ injury include all of the
  following EXCEPT:

•    abdominal pain and tenderness
•    early bacterial peritonitis
•    development of rebound, guarding and rigidity
•    hypotension and tachycardia
•    palpable mass and radiographic mass effect (may result from
    confined hemorrhage)
         DIAGNOSTIC STRATEGIES

• Hct: can be a delayed sign, should do serial.
• WBC:  in stress, peritoneal irritation
• Pancreatic enzymes: if normal, does NOT r/o
  pancreatic injury
   amylase: EtOH, narcotics
 amylase & lipase: ischemia 2 hypotension
 both non-specific & non-sensitive for pancreatic
  injuries
• Are abdo x-rays useful in trauma?



      Although plain abdominal films can demonstrate
  numerous findings, their place in acute trauma is
  limited. Because of spinal precautions, hemodynamic
  instability, time consuming or patient discomfort.
    Smaller diaphragmatic injuries are often missed, with
     herniation occurring late as the negative intrathoracic
     pressure gradually draws the mobile abdominal organs into
     the chest. Early radiographic findings may be absent or
     subtle and include all of the following EXCEPT :

•     pleural effusion
•     appearance of the nasogastric tube in the chest
•     appearance of bowel loops in the chest
•     elevation of the diaphragm
•     blurring of the diaphragm
    Smaller diaphragmatic injuries are often missed, with
     herniation occurring late as the negative intrathoracic
     pressure gradually draws the mobile abdominal organs into
     the chest. Early radiographic findings may be absent or
     subtle and include all of the following EXCEPT :

•     pleural effusion
•     appearance of the nasogastric tube in the chest
•     appearance of bowel loops in the chest
•     elevation of the diaphragm
•     blurring of the diaphragm
                             Imaging
• CT                                 • US
  – Able to define organ injury        – Good for solid organs
  – Good for retroperitoneal &         – Portable
    vertebral column                   – Fast
  – Non-invasive                       – 100 cc detection blood
  – Not Operator dependant             – Mediastinum evaluation
                                       – No radiation
                                       – No contrast need
  –    Not great for hollow viscus     – Not see well: solid
  –    Stable patient                    parenchymal, retroperitoneal,
  –    Cost $$$                          diaphragm
  –    Complications: IV or oral       – Problem if: obesity, gas
       contrast                        – Less sensitive than DPL for
                                         hemoperitoneal
                                       – Operator dependant
20 y/o female patient involved in a low velocity MVA. Upon initial exam no
abnormalities noted, no complains.
The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT
Scan which showed Liver Laceration Grade III. This patient was treated non-
operatively.
    Preferred Site of Diagnostic Peritoneal Lavage




•    Standard adult :Infraumbilical midline C or SO
•    Standard pediatric: Infraumbilical midline C or SO
•    2ed &3ed trimester pregnancy :Suprauterine FO
•    Midline scarring :Left lower quadrant FO
•    Pelvic fracture: Supraumbilical FO
DPL RBC Criteria (per mm3 )
                   Positive   Indeterminate
           Blunt    100,000      20–100,000
   Stab wound
Anterior abdomen    100,000     20,000–100,000
          Flank     100,000     20,000–100,00
           Back     100,000    20,000–100,000
   Low chest        5000        1000-5000
Gunshot wound       5000        1000-5000
• List causes false negative DPL?
Catheter preperitoneal space
Fluid in compartment 2 adhesions
Diaphragmatic tear, so fluid goes into thoracic cavity
                                                         •
-sole absolute contraindication to DPL is the established
  need for laparotomy.


Relative contraindications:
- prior abdominal surgery
- Infections
- Coagulopathy
- obesity
- second- or third-trimester pregnancy.
CLINICAL APPROCHES TO PT WITH:

o   BLUNT ABDOMINAL TRAUMA
o   STAB WOUND
o   GUNSHOT
o   ABDOMINAL WITH PELVIC TRAUMA.
Clinical Indications for Laparotomy after Blunt
                    Trauma
Manifestation                  Pitfall
Unstable vital signs with    Alternate sources shock
strongly suspected abdominal
injury
Unequivocal peritoneal         Unreliable
irritation
Pneumoperitoneum               Insensitive; may be due to
                               cardiopulmonary source or invasive
                               procedures (diagnostic peritoneal
                               lavage, laparoscopy)
Evidence of diaphragmatic      Nonspecific
injury
Significant gastrointestinal   Uncommon, unknown accuracy
bleeding
    Approach to abdominal stab
             wound.


• Step I: Clinical Indications for Laparotomy.
• Step II: Peritoneal Violation.
• Step III: Injury Requiring Laparotomy.
Clinical Indications for Laparotomy Following
              Penetrating Trauma
Manifestation             Premise                          Pitfall
Hemodynamic instability   Major solid visceral or          Thorax or mediastinum,
                          vascular injury                  causal or contributory
Peritoneal signs          Intraperitoneal injury           Unreliable, especially
                                                           immediately post-injury
Evisceration              Additional bowel, other injury   No injury in one fourth to one
                                                           third of stab wound cases
Diaphragmatic injury      Diaphragm                        Rare clinical, radiographic
                                                           findings
Gastrointestinal          Proximal gut                     Uncommon, unknown
hemorrhage                                                 accuracy

Implement in situ         Vascular impalement              Comorbid disease or
                                                           pregnancy creates high
                                                           operative risk
Intraperitoneal air       Hollow viscus perforation        Insensitive; may be caused by
                                                           intraperitoneal entry only or be
                                                           due to cardiopulmonary
                                                           source
            Peritoneal Violation.

•   1.   Evisceration
•   2.   Intraperitoneal air
•   3.   Local wound exploration
•   4.   Ultrasonography
•   5.   Laparoscopy
Stab wound to right lower quadrant with caecal
evisceration. No colon injury at laparotomy.
• Eviscerated omentum is easily mistaken for subcutaneous
  fat, so care must be taken in the examination of open
  abdominal injuries. Which of the following statements
  regarding abdominal evisceration treatment is FALSE?

• Cover eviscerated organs with moist gauze or petrolatum
  gauze (to prevent desiccation) for replacement at laparotomy.
• Return all eviscerated organs to the peritoneal cavity.
• Only organs with vascular compromise should be promptly
  returned to the abdominal cavity.
• Eviscerated omentum is easily mistaken for subcutaneous
  fat, so care must be taken in the examination of open
  abdominal injuries. Which of the following statements
  regarding abdominal evisceration treatment is FALSE?

• Cover eviscerated organs with moist gauze or petrolatum
  gauze (to prevent desiccation) for replacement at laparotomy.
• Return all eviscerated organs to the peritoneal cavity.
• Only organs with vascular compromise should be promptly
  returned to the abdominal cavity.
• In the abdominal stab wound victim without clear indications for
  exploration (obvious peritoneal penetration, unexplained hypotension, or
  signs of peritoneal irritation), local wound exploration with local
  anesthesia should be performed; laparotomy should be performed if the __
  is penetrated.

•   rectus abdominis muscle
•   posterior rectus sheath
•   transversalis fascia.
25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar entered
at the level of the epigastrium and exited through the left posterior thoracic wall.




                                        Abdominal stab wound, with hepatic
                                        .lesion grade II
                  Implements in situ
• implements in situ of the torso in the operating room.
 to ensure expeditious control of hemorrhage
 the implement reside within a vascular space or highly vascularized organ.



• exceptions to this practice exist:
 situations in which emergency department resuscitation is impeded by
  the presence of the implement
 the patient is at high risk of significant morbidity from nontherapeutic
  laparotomy because of severe comorbid conditions or pregnancy.
What is your approach to pelvic #?•
conculsion
• The accuracy of physical examination is limited in cases of
  blunt and penetrating trauma. It is less reliable by distracting
  injury, altered sensorium (e.g., head trauma, alcohol or drug
  intoxication, mental retardation), and spinal cord injury.

• The choice of diagnostic studies for abdominal trauma is
  based on clinical need first and foremost, as well as study
  availability and the trustworthiness of that study in a
  respective center
• Ultrasonography and peritoneal aspiration are rapid methods
  of determining or excluding the presence of hemoperitoneum
  in the critically ill blunt or penetrating trauma patient.




• Clinical indications for laparotomy are more dependable in
  and more frequently applicable to cases of penetrating
  trauma than cases of blunt trauma.
THANK YOU

								
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