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Case-Based Abdominal Trauma

Case-Based Abdominal Trauma - Case­Based Abdominal...

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Unformatted text preview: Case­Based Abdominal Case­Based Abdominal Trauma Dr. Maggio and Ellen Morrow 1 case st The patient is a 24­year­old female rollover motor vehicle accident with GCS approximately 6 to 8 on scene. Her car rolled down a cliff, alcohol was involved. The patient was the unrestrained driver and was ejected. She was unresponsive in the field. Trauma assessment Trauma assessment 2/28 7:25 pm P 97 86/50 100% FAST – Unresponsive Exam: scalp lac, facial abrasion and R orbital trauma, abdomen “normal” Blunt Abdominal Trauma Blunt Abdominal Trauma CT Indications Spinal cord injury, GCS < 9 Significant abdominal pain or tenderness Gross hematuria Non­ramus pelvic fracture Significant chest trauma Unexplained tachycardia/hypotension (with normal ultrasound) Ultrasound Indications Hypotension CT Abd Pelvis CT Abd Pelvis Liver injuries Liver injuries May be most common (vs spleen) in blunt abd trauma 95% of grade 1­3 can be managed non­op If there is extravisation, consider angio or OR Mobilize and feed when no evidence of bleed, no contact sports x 3 months post­injury CT criteria for staging liver trauma CT criteria for staging liver trauma Grade 1 ­ Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking Grade 2 ­ Parenchymal laceration 1­3 cm deep and parenchymal/subcapsular hematomas 1­3 cm thick Grade 3 ­ Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter Grade 4 ­ Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization Grade 5 ­ Global destruction or devascularization of the liver Grade 6 ­ Hepatic avulsion Blunt Liver Injury: Treatment Blunt Unstable patients: mandatory laparotomy Stable patients: selective nonoperative Stable approach approach Hepatic injury Hepatic -Usually venous bleeding -Usually -Grade I-III: 94% success w/ nonop -Grade treatment treatment -Grade IV-V: 20% amenable to nonop tx -HD stability, stable Hct, observation -Complications: delayed hemorrhage, bile -Complications: leak, biloma, intra/peri hepatic abscess. -If stable with ongoing bleeding angiographic embolization angiographic Blunt Splenic Trauma: Adult Consider early operative intervention in patients with severe brain injury, multisystem injuries, or medical comorbidities. There is risk of transfusion reactions, disease transmission and infectious morbidity with blood transfusion. At present, there are no studies establishing the safety of LMWH in patients with blunt splenic injury and this choice is at the discretion of the attending surgeon. Splenectomized patients should undergo meningococcal, pneumococcal, and Hib vaccines. The optimal timing is 14 days post­splenectomy. If there is legitimate concern about a patient not returning, vaccinate prior to discharge. At present, there are no studies evaluating the immunologic function of the embolized spleen or the need for vaccination after splenic angioembolization. Plain film findings for spleen lac Plain film findings for spleen lac The most common finding associated with splenic injury is left lower rib fracture. Rib fractures signify that adequate force has been transmitted to the LUQ to cause splenic pathology. Left lower rib fracture is present in 44% of patients with splenic rupture and necessitates further workup by abdominal CT. The classic triad indicative of acute splenic rupture (ie, left hemidiaphragm elevation, left lower lobe atelectasis, and pleural effusion) is not commonly present and should not be regarded as a reliable sign. However, any patient with apparent left hemidiaphragm elevation following blunt abdominal trauma should be considered to have splenic injury until proven otherwise. Grading spleen lacs Grading spleen lacs Grade I Grade II Subcapsular hematoma of 10­50% of surface area Intraparenchymal hematoma of less than 5 cm in diameter Laceration of 1­3 cm in depth and not involving trabecular vessels Grade III Subcapsular hematoma of less than 10% of surface area Capsular tear of less than 1 cm in depth Subcapsular hematoma of greater than 50% of surface area or expanding and ruptured subcapsular or parenchymal hematoma Intraparenchymal hematoma of greater than 5 cm or expanding Laceration of greater than 3 cm in depth or involving trabecular vessels Grade IV ­ Laceration involving segmental or hilar vessels with devascularization of more than 25% of the spleen Grade V ­ Shattered spleen or hilar vascular injury Blunt Abdominal Trauma Blunt SPLENIC INJURIES Often arterial hemorrhage, therefore nonoperative Often management less successful. Predictive factors for nonop success: Predictive Localized trauma to flank/abdomen Age<60 No associated trauma precluding obs Transfusion <4u prbcs Grade I-III Grade IV-V: almost invariably require operative Grade intervention intervention Delayed hemorrhage (hours to weeks post-injury): 821% Renal Trauma Ten percent of patients with blunt abdominal trauma are found to have a urogenital injury. Renal parenchymal injuries are the most common. Of these injuries, 75–90% may be classified as minor (Grade I­III) and require no intervention. Work up and treatment of the remaining “major” renal injuries has been controversial but there has been increasing interest in non­operative management because of associated decreased transfusion requirement, shorter ICU stay, and increased salvage rate of the kidney. CT scan of the abdomen/pelvis is the test of choice for staging renal injury. Evaluation: Urine from the first post injury void should be evaluated on all patients with blunt abdominal trauma. Most patients with major renal trauma present with gross hematuria or hypotension, only 0.8 – 1.2% of major renal injuries have neither. Microscopic hematuria (Greater than 5 RBC/HPF): Rarely associated with significant renal system injury. Patients require observation and repeat UA later in the ER or hospital to demonstrate resolution, in order to rule out other sources of hematuria such as malignancy. Children with significant microscopic hematuria (Greater than 50 RBC/HPF) should undergo abdominal/pelvic CT with Cystogram as their risk for significant renal injury is higher than in adults. Gross hematuria: Patients require abdominal/pelvic CT with cystogram if hemodynamically stable. A retrograde urethrogram should be performed if there is blood at the meatus. Blunt vs. penetrating: Blunt injury and stab wounds may be worked up in a similar fashion. Gunshot injuries often skip CT scan staging and require exploration because of hypotension, massive injury and delayed complications secondary to blast effect. Evaluation for Blunt Bowel or Mesenteric Injury Evaluation for Blunt Bowel or Mesenteric Injury 2/29 1:20 AM A.V. 2/29 1:20 AM A.V. Went to IR for splenic artery embolization, L hepatic artery embolization, coil embolization of R renal artery, IVC filter Received 3 units PRBC, HCT 28.6­>36.4 2 case nd 18M presents to trauma bay with multiple stab wounds. He is awake and c/o pain. HR 115 but otherwise VSS. Stab wounds are ~2cm in size, located below left costal margin, left flank, and left back. Truncal Stab Wounds The purpose of this algorithm is to guide the management of patients with stab wounds to the anterior abdomen, thoracoabdominal area, back, and flank. Anterior abdominal stab wounds are defined as those anterior to the mid­axillary line, from the xiphoid process to the pubic symphysis. Although optimal management of stable patients with AASW is debated, we have adopted a protocol of serial clinical assessments to determine the need for laparotomy. Retrospective review of RIH data suggests that this is a safe and effective approach in our institution.1 Thoracoabdominal stab wounds are defined as those between a circumferential line connecting the nipples and tips of the scapulae superiorly, and the costal margins inferiorly. Occult diaphragmatic injury is problematic in this patient group.2 We have selected DPL as the preferred diagnostic modality to exclude diaphragmatic injury, with a RBC cutoff of 5000/mm3 chosen to balance sensitivity and specificity.3 Back/Flank stab wounds are defined as those between the tips of the scapulae and posterior iliac crests, posterior to the mid­axillary line. Physical examination alone is unreliable in this group, and DPL is unable to evaluate the retroperitoneum. Triple contrast (oral, rectal, and intravenous) CT has a sensitivity of 89­100% and a specificity of 98­100% in diagnosing intra­abdominal and retroperitoneal injuries.4­7 Penetrating Abdominal Trauma Penetrating Stab Wounds: Stratification by loci Stab Stratification Thoracoabdominal Flank Anterior Abdominal Anterior Explore locally, manage expectantly with serial PE with Back Peristernal Peristernal Potential Mediastinal Mediastinal Penetrating Abdominal Trauma Penetrating Stab Wounds: Stratification by loci Stab Stratification Lower Chest Flank explore locally triple contrast triple CT CT Anterior Abdominal Anterior Explore locally, manage expectantly with serial PE with Back Peristernal Peristernal Potential Mediastinal Mediastinal 3 case rd 60F pedestrian vs auto presents to trauma bay Primary survey: airway clear, bilat BS, 1+ radial pulses VS: HR 105, BP 115/70 3 case rd Secondary survey: PMH: on coumadin for afib Abd mild TTP lower abdomen, FAST ­, pelvis unstable. Pelvic fractures: challenges Pelvic fractures: challenges Brisk bleeding with damage to surrounding vascular structures Secondary coagulopathy High rate of associated extrapelvic injuries Pelvic fxs + hypotension; mortality 36% If laparotomy required, mortality 58% Early mechanical stabilization and/or IR can help 3 case cont. rd The patient goes to the OR for emergent ex­fix b/c they were hemodynamically unstable in the trauma bay. They have not yet had an abdominal CT scan. 3 case cont. rd You decide to explore the abdomen. You find a large billowing pelvic hematoma. Retroperitoneal Retroperitoneal hematomas Blunt: explore all central (1) explore lateral or pelvic if expanding Penetrating: explore all References References Biffl, Trauma Handbook, RIH Dept of Surgery, Division of Trauma and Surgical Critical Care. Greenfield Cindy Kin: Abdominal Trauma, SICU conference 1/8/08 Emedicine: liver and spleen trauma. ...
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