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Abdominal Trauma _Azimi_

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      Abdominal Trauma

Soheil Azimi , Student Of Medicine

     Islamic Azad University
     Tehran Medicine Unit
    The abdomen is frequency injured after both
    blunt and penetrating trauma.
    Approximately 25% of all trauma victims will
    require an abdominal exploration.
       The Plan

   Abdominal Anatomy
   Mechanisms of Injury
   Common Pathology
   Evaluation
   Management
     Part 1:
Abdominal Anatomy
      Abdominal Anatomy Basics
   Many organs receiving substantial blood flow
   Potential spaces that can hide hemorrhage
   Hollow organ damage > Peritonitis
      Abdominal Anatomy Basics
   Many organs receiving substantial blood flow
   Potential spaces that can hide hemorrhage
   Hollow organ damage > Peritonitis
      Abdominal Anatomy Basics
   Many organs receiving substantial blood flow
   Potential spaces that can hide hemorrhage
   Hollow organ damage > Peritonitis
Abdominal Anatomy:
  Four Quadrants
Abdominal Anatomy:
  Four Quadrants
Abdominal Anatomy
Abdominal Anatomy
Abdominal Anatomy
Alternative Divisions
Lower Abdomen CT
Retroperitoneal
External Anatomy of Abdomen
    Part 2:
Mechanisms and
  Pathology
            Abdominal Injuries
   Blunt vs. Penetrating

   Often both occur simultaneously

   Blunt is the most common mechanism in US
        Blunt Abdominal Trauma
   Direct impact or
    movement of organs
   Compressive, stretching
    or shearing forces
   Solid Organs > Blood
    Loss
   Hollow Organs > Blood
    Loss and Peritoneal
    Contamination
   Retroperitoneal > Often
    asymptomatic initially
        Blunt Abdominal Trauma
   Direct impact or
    movement of organs
   Compressive, stretching
    or shearing forces
   Solid Organs > Blood
    Loss
   Hollow Organs > Blood
    Loss and Peritoneal
    Contamination
   Retroperitoneal > Often
    asymptomatic initially
        Blunt Abdominal Trauma
   Direct impact or
    movement of organs
   Compressive, stretching
    or shearing forces
   Solid Organs > Blood
    Loss
   Hollow Organs > Blood
    Loss and Peritoneal
    Contamination
   Retroperitoneal > Often
    asymptomatic initially
        Blunt Abdominal Trauma
   Direct impact or
    movement of organs
   Compressive, stretching
    or shearing forces
   Solid Organs > Blood
    Loss
   Hollow Organs > Blood
    Loss and Peritoneal
    Contamination
   Retroperitoneal > Often
    asymptomatic initially
        Blunt Abdominal Trauma
   Direct impact or
    movement of organs
   Compressive, stretching
    or shearing forces
   Solid Organs > Blood
    Loss
   Hollow Organs > Blood
    Loss and Peritoneal
    Contamination
   Retroperitoneal > Often
    asymptomatic initially
           Mechanism of Injury: Penetrating

● Stab
  ● Low energy, lacerations

● Gunshot
  ● Kinetic energy transfer
     ● Cavitation, tumble

     ● Fragments
                 Abdominal Injury
Factors that Compromise the Exam
● Alcohol and other drugs
● Injury to brain, spinal cord
● Injury to ribs, spine, pelvis



                        Caution

                                  A missed abdominal
                                   injury can cause a
                                   preventable death.
      Techniques for Evaluation
Physical Exam
 Serial exams in awake, alert and reliable pt

Plain Films
 Abd films little or no use, pelvis are the standard

Screening
 Diagnostic Peritoneal Lavage (DPL)

 Ultrasound: FAST (serial exams)
DPL: Procedure
     Diagnostic Peritoneal Lavage
      Introduced by Root (1965)
      Indications for DPL in blunt trauma:
    1.     Hypotension with evidence of abdominal injury

    2.   Multiple injuries and unexplained shock

    3.   Potential abdominal injury in patients who are unconscious,
         intoxicated, or paraplegic

    4.   Equivocal physical findings in patients who have sustained high-energy
         forces to the torso

    5.   Potential abdominal injury in patients who will undergo prolonged
         general anesthesia for another injury, making continued reevaluation of
         the abdomen impractical or impossible
            Contraindications of DPL
   Absolute :
        Peritonitis
        Injured diaphragm
        Extraluminal air by x-ray
        Significant intraabdominal injury by CT scan
        Intraperitoneal perforation of the bladder by cystography


   Relative :
        Previous abdominal operations (because of adhesions)
        Morbid obesity
        Gravid Uterus
        Advanced cirrhosis (because of portal hypertension and the risk of
         bleeding)
        Preexisting coagulopathy
FAST
    Focused Abdominal Sonography for Trauma
                   (FAST)
   Demonstrate presence of free intraperitoneal fluid

   Evaluate solid organ hematomas

   Advantages
       No risk from contrast media or radiation
       Rapid results, portability, non-invasive, ability to repeat exams.

   Disadvantages
       Cannot assess hollow visceral perforation
       Operator dependent
       Retroperitoneal structures are not visualized
                                   FAST
   Four View Technique:
       Morrison’s pouch (hepatorenal)
       Douglas pouch (retropelvic)
       Left upper quadrant (splenic view)
       Epigastric (View pericardium)
Algorithm for the evaluation of penetrating abdominal injuries




   AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage;
    GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper quadrant; SW = stab wound.
    Algorithm for the initial evaluation of a patient with suspected blunt
                              abdominal trauma




    CT = computed tomography; DPA = diagnostic peritoneal aspiration; FAST = focused
     abdominal sonography for trauma; Hct = hematocrit
Genitourinary Trauma
                 GU Trauma
   2-5% of adult traumas
   Vast majority blunt mechanisms
   80% renal injuries
   10% bladder injuries
   Abnormalities (tumor, hydro) increase
    susceptibility
   Rarely require immediate intervention
                  Evaluation
   Rectal - high riding prostate
   Perineum - ecchymosis, lacs
   Genitals - meatal/vaginal blood
   Difficult catheter placement (may need
    suprapubic)
   UA – hematuria (poor correlation to degree of
    injury)
                  Evaluation
   U/S and Plain films of little use
   CT is the superior imaging modality
   Careful with contrast (nephropathy)
   Angiography remains the gold standard
   IVP/Cystoscopy less useful
       GU Injuries: The Kidneys
   Kidneys are well protected
   Most commonly bruised
   Pts with a shattered kidney become rapidly
    unstable
   Renal vascular injuries may result in thrombosed
    vessels
     GU Injuries: The Kidneys
Operative management for:
 uncontrolled hemorrhage

 Penetrating injuries

 Multiple lacs

 Shattered kidney

 Avulsed vessels
        GU Injuries: The Bladder
   Contusion
   Rupture: Intra vs. Extraperitoneal
   Extraperitoneal presents with pain, hematuria
    and inability to void
   Urethral injuries: Anterior vs. posterior
   No Foley for urethral injuries
                In Summary...
   Basic knowledge of anatomy necessary for initial
    assessment of abdominal trauma
   Peritoneal vs. Retroperitoneal
   Blunt vs. Penetrating
   Don’t miss GU injuries
Thank You

				
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posted:8/16/2012
language:English
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