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Abdominal Trauma 4.18.58 PM

Abdominal Trauma 4.18.58 PM - Blunt Abdominal Trauma...

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Unformatted text preview: Blunt Abdominal Trauma: Evaluation Trauma Conference Trauma January 9th, 2006 Greg Feldman, MD PGY1, General Surgery Department Stanford Medical Center Outline Outline Anatomic definition of abdomen Mechanisms of injury in blunt trauma Typical injury patterns Assessment of blunt abdominal trauma Diagnostic algorithms Abdomen: anatomic boundaries Abdomen: External: Anterior abdomen: transnipple line superiorly, inguinal ligaments and Anterior symphasis pubis inferiorly, anterior axillary lines laterally. symphasis Flank: between anterior and posterior axillary lines from 6th intercostals Flank: space to iliac crest. space Back: Posterior to posterior axillary lines, from tip of scapulae to iliac crests. Internal: Upper peritoneal cavity: covered by lower aspect of bony thorax. Includes Upper diaphragm, liver, spleen, stomach, transverse colon. diaphragm, Lower peritoneal cavity: small bowel, ascending and descending colon, Lower sigmoid colon, and (in women) internal reproductive organs. sigmoid Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women) Pelvic internal reproductive organs. internal Retroperitoneal space: posterior to peritoneal lining of abdomen. Abdominal Retroperitoneal aorta, IVC, most of duodenum, pancreas kidneys, ureters, and posterior aspects of ascending and descending colon. aspects Mechanisms of injury Mechanisms Compression, crush, or sheer injury to abdominal viscera Compression, deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus) bowel, Deceleration injuries: differential movements of fixed and Deceleration nonfixed structures (e.g. liver and spleen lacs at sites of supporting ligaments) supporting Common injury patterns Common In patients undergoing laparotomy for blunt trauma, most frequently In injured organs are spleen (40-55%), liver (35-45%), and small bowel (5injured 10%). (ATLS, 2001) Duodenum: Classically, frontal-impact MVC with unrestrained driver; or direct blow to Classically, abdomen. abdomen. Bloody gastric aspirate, retroperitoneal air on XR or CT Confirmed with upper GI series or double contrast CT Small bowel injury: Generally from sudden deceleration with subsequent tearing near fixed Generally points of attachment. points Often associated with seat belt sign, lumbar distraction fracture (Chance Often fracture) fracture) DPL superior to FAST or CT for diagnosis. Common injury patterns (2) Common Pancreas: Direct epigastric blow compressing pancreas against vertebral column. Early normal serum amylase does NOT exclude major pancreatic trauma. CT with PO/IV contrast – NOT particularly sensitive in immediate postinjury period. Diaphragm: Most commonly, 5-10 cm rupture involving posterolateral hemidiaphragm. Noted on CXR: blurred or elevated hemidiaphragm, hemothorax, GT in Noted chest chest Genitourinary: Anterior injuries (below UG diaphragm): usually from straddle impact. Posterior injuries (above UG diaphragm): in patient with multisystem Posterior injuries and pelvic fractures. injuries Common injury patterns (3) Common Solid organ injury Laceration to liver, spleen, or kidney Injury to one of these three + hemodynamic instability: considered Injury indication for urgent laparotomy indication Isolated solid organ injury in hemodynamically stable patient: can Isolated often be managed nonoperatively. often Pelvic fractures: Suggest major force applied to patient. Usually auto-ped, MVC, or motorcycle Significant association with intraperitoneal and retroperitoneal Significant organs and vascular structures. organs Restraining devices Restraining Lap seat belt Shoulder Harness Mesenteric tear or avulsion Rupture of small bowel or colon Iliac artery or abdominal aorta thrombosis Chance fracture of lumbar vertebrae (hyperflexion) Rupture of upper abdominal viscera Intimal tear or thrombosis in innominate, carotid, subclavian, or vertebral arteries Fracture or dislocation of C-spine Rib fractures Pulmonary contusion Air Bag Corneal abrasions, keratitis Abrasions of face, neck, chest Cardiac rupture C or T-spine fracture Assessment: History Assessment: Mechanism Symptoms, events, PMH, Meds, EtOH/drugs MVC: Speed Type of collision (frontal, lateral, sideswipe, rear, Type rollover) rollover) Vehicle intrusion into passenger compartment Types of restraints Deployment of air bag Patient's position in vehicle Assessment: Physical Exam Assessment: Inspection, auscultation, percussion, palpation Inspection: abrasions, contusions, lacerations, deformity Grey-Turner, Kehr, Balance, Cullen Auscultation: careful exam advised by ATLS. Auscultation: (Controversial utility in trauma setting.) (Controversial Percussion: subtle signs of peritonitis; tympany in gastric Percussion: dilatation or free air; dullness with hemoperitoneum dilatation Palpation: elicit superficial, deep, or rebound tenderness; Palpation: involuntary muscle guarding involuntary Physical Exam: Eponyms Physical Grey-Turner sign: Bluish discoloration of lower flanks, lower back; associated with Bluish retroperitoneal bleeding of pancreas, kidney, or pelvic fracture. retroperitoneal Cullen sign: Bluish discoloration around umbilicus, indicates peritoneal bleeding, Bluish often pancreatic hemorrhage. often Kehr sign: L shoulder pain while supine; caused by diaphragmatic irritation shoulder (splenic injury, free air, intra-abd bleeding) (splenic Balance sign: Dull percussion in LUQ. Sign of splenic injury; blood accumulating Dull in subcapsular or extracapsular spleen. in Diagnostic adjuncts Diagnostic Labs: BMP, CBC, coags, b-HCG, amy/lip, U/A, tox screen, Labs: T&C T&C Plain films: CXR, pelvis; abd films generally lower priority DPL FAST CT Diagnostic Peritoneal Lavage Diagnostic 98% sensitive for intraperitoneal bleeding (ATLS) Open or closed (Seldinger); usually infraumbilical, but may be Open supraumbilical in pelvic frxs or advanced pregnancy. supraumbilical Free aspiration of blood, GI contents, or bile in demodynamically Free abnormal pt: indication for laparotomy abnormal If gross blood (> 10 mL) or GI contents not aspirated, perform lavage If with 1000 mL warmed LR. Allow to mix, compress abdomen and logross paient, the sent to lab. + test: >100,000 RBC/mm3, >500 WBC/mm3, Gram stain with bacteria. WBC/mm3, Alters subsequent examination of patient Has been somewhat superceded by FAST in common use; now generally Has performed in unstable patients with intermediate FAST exams, or with suspicion for small bowel injury. suspicion FAST: Strengths and Limitations FAST: Strengths Rapid (~2 mins) Portable Inexpensive Technically simple, easy to train Technically (studies show competence can be achieved after ~30 studies) achieved Can be performed serially Useful for guiding triage decisions Useful in trauma patients in Limitations Does not typically identify source of Does bleeding, or detect injuries that do not cause hemoperitoneum not Requires extensive training to assess Requires parenchyma reliably parenchyma Limited in detecting <250 cc Limited intraperitoneal fluid intraperitoneal Particularly poor at detecting bowel Particularly and mesentery damage (44% sensitivity) sensitivity) Difficult to assess retroperitoneum Difficult Limited by habitus in obese patients FAST: Accuracy FAST: For identifying hemoperitoneum in blunt abdominal trauma: Sensitivity 76 - 90% Specificity 95 - 100% The larger the hemoperitoneum, the higher the sensitivity. So The sensitivity increases for clinically significant hemoperitoneum. hemoperitoneum. How much fluid can FAST detect? 250 cc total 100 cc in Morison’s pouch Does FAST replace CT? Does Only at the extremes. Unstable patient, (+) FAST OR Unstable Stable patient, low force injury, (-) FAST consider Stable observing patient. CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. The gold standard for characterizing intraparenchymal injury. standard “Death begins with a CT.” Never send an unstable patient to Death CT. FAST, however, can be performed during resuscitation. resuscitation. CT CT EAST level I recommendations (2001): CT is recommended for evaluation of hemodynamically CT stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple extra-abdominal injuries. extra-abdominal CT is the diagnostic modality of choice for nonoperative CT management of solid visceral injuries. management EAST Algorithm: Unstable EAST Eastern Association for the Surgery of Trauma, 2001 EAST Algorithm: Stable EAST Eastern Association for the Surgery of Trauma, 2001 References References Hoff et al. EAST Practice Management Guidelines Work Group. Hoff Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma, 2001. www.east.org. Abdominal American College of Surgeons Committee on Trauma. American Advanced Trauma Life Support for Doctors; Student Course Manual, 7th edition, 2004. Manual, Scalea TM, Rodriquez A, Chiu WC. Focused Assessment with Scalea Sonography for Trauma (FAST): Results from an International Consensus Conference. J. Trauma 1999;46:466-472. 1999;46:466-472. Yoshii H, Sato M, Yamamoto S. Usefulness and Limitations of Yoshii Ultrasonography in the Initial Evaluation of Blunt Abdominal Trauma. J. Trauma 1998;45:45-51. J. Acknowledgements Acknowledgements Dr. Shelly Erford Dr. Denny Jenkins Carol Thomson Dr. Natalie Kirilchik Dr. Subarna Biswas Drs. Brundage, Spain, and Gregg Stanford Medical Center ACS/Trauma Service Noah Feinstein Dr. Gillian Lieberman Dr. Jason Tracy ...
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