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Unformatted text preview: Blunt Abdominal 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
symphasis pubis inferiorly, anterior axillary lines laterally.
symphasis Flank: between anterior and posterior axillary lines from 6th intercostals
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
diaphragm, liver, spleen, stomach, transverse colon.
diaphragm, Lower peritoneal cavity: small bowel, ascending and descending colon,
sigmoid colon, and (in women) internal reproductive organs.
sigmoid Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women)
internal reproductive organs.
internal Retroperitoneal space: posterior to peritoneal lining of abdomen. Abdominal
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
nonfixed structures (e.g. liver and spleen lacs at sites of
supporting Common injury patterns
Common In patients undergoing laparotomy for blunt trauma, most frequently
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
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
points of attachment.
points Often associated with seat belt sign, lumbar distraction fracture (Chance
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
chest Genitourinary: Anterior injuries (below UG diaphragm): usually from straddle impact. Posterior injuries (above UG diaphragm): in patient with multisystem
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
indication for urgent laparotomy
indication Isolated solid organ injury in hemodynamically stable patient: can
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
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
Pulmonary contusion Air Bag Corneal abrasions, keratitis
Abrasions of face, neck, chest
C or T-spine fracture Assessment: History
Symptoms, events, PMH, Meds, EtOH/drugs
MVC: Speed Type of collision (frontal, lateral, sideswipe, rear,
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.
(Controversial utility in trauma setting.)
(Controversial Percussion: subtle signs of peritonitis; tympany in gastric
dilatation or free air; dullness with hemoperitoneum
dilatation Palpation: elicit superficial, deep, or rebound tenderness;
involuntary muscle guarding
involuntary Physical Exam: Eponyms
Physical Grey-Turner sign: Bluish discoloration of lower flanks, lower back; associated with
retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.
retroperitoneal Cullen sign: Bluish discoloration around umbilicus, indicates peritoneal bleeding,
often pancreatic hemorrhage.
often Kehr sign: L shoulder pain while supine; caused by diaphragmatic irritation
(splenic injury, free air, intra-abd bleeding)
(splenic Balance sign: Dull percussion in LUQ. Sign of splenic injury; blood accumulating
in subcapsular or extracapsular spleen.
in Diagnostic adjuncts
Diagnostic Labs: BMP, CBC, coags, b-HCG, amy/lip, U/A, tox screen,
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
supraumbilical in pelvic frxs or advanced pregnancy.
supraumbilical Free aspiration of blood, GI contents, or bile in demodynamically
abnormal pt: indication for laparotomy
abnormal If gross blood (> 10 mL) or GI contents not aspirated, perform lavage
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
performed in unstable patients with intermediate FAST exams, or with
suspicion for small bowel injury.
suspicion FAST: Strengths and Limitations
Strengths Rapid (~2 mins) Portable Inexpensive Technically simple, easy to train
(studies show competence can be
achieved after ~30 studies)
achieved Can be performed serially Useful for guiding triage decisions
in trauma patients
in Limitations Does not typically identify source of
bleeding, or detect injuries that do
not cause hemoperitoneum
not Requires extensive training to assess
parenchyma Limited in detecting <250 cc
intraperitoneal Particularly poor at detecting bowel
and mesentery damage (44%
sensitivity) Difficult to assess retroperitoneum
Difficult Limited by habitus in obese patients FAST: Accuracy
For identifying hemoperitoneum in blunt abdominal trauma: Sensitivity 76 - 90% Specificity 95 - 100%
The larger the hemoperitoneum, the higher the sensitivity. So
sensitivity increases for clinically significant
How much fluid can FAST detect? 250 cc total 100 cc in Morison’s pouch Does FAST replace CT?
Only at the extremes. Unstable patient, (+) FAST OR
Unstable Stable patient, low force injury, (-) FAST consider
CT is far more sensitive than FAST for detecting and
characterizing abdominal injury in trauma. The gold
standard for characterizing intraparenchymal injury.
“Death begins with a CT.” Never send an unstable patient to
CT. FAST, however, can be performed during
EAST level I recommendations (2001): CT is recommended for evaluation of hemodynamically
stable patients with equivocal findings on physical
examination, associated neurologic injury, or multiple
extra-abdominal CT is the diagnostic modality of choice for nonoperative
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.
Practice Management Guidelines for the Evaluation of Blunt
Abdominal Trauma, 2001. www.east.org.
American College of Surgeons Committee on Trauma.
Advanced Trauma Life Support for Doctors; Student Course
Manual, 7th edition, 2004.
Scalea TM, Rodriquez A, Chiu WC. Focused Assessment with
Sonography for Trauma (FAST): Results from an International
Consensus Conference. J. Trauma 1999;46:466-472.
Yoshii H, Sato M, Yamamoto S. Usefulness and Limitations of
Ultrasonography in the Initial Evaluation of Blunt Abdominal
Trauma. J. Trauma 1998;45:45-51.
Acknowledgements Dr. Shelly Erford
Dr. Denny Jenkins
Dr. Natalie Kirilchik
Dr. Subarna Biswas
Drs. Brundage, Spain, and Gregg
Stanford Medical Center ACS/Trauma Service
Dr. Gillian Lieberman
Dr. Jason Tracy ...
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