Transcript Abdominal trauma - Oman Medical Specialty Board

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?
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*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?
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*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.
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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.
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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:
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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:
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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 :
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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 :
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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 retroperitoneal &
vertebral column
– Non-invasive
– Not Operator dependant
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Not great for hollow viscus
Stable patient
Cost $$$
Complications: IV or oral
contrast
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Good for solid organs
Portable
Fast
100 cc detection blood
Mediastinum evaluation
No radiation
No contrast need
Not see well: solid
parenchymal, retroperitoneal,
diaphragm
– Problem if: obesity, gas
– 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 nonoperatively.
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
100,000
20–100,000
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
5000
1000-5000
Blunt
Stab wound
Gunshot wound
• 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:
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o
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BLUNT ABDOMINAL TRAUMA
STAB WOUND
GUNSHOT
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
irritation
Unreliable
Pneumoperitoneum
Insensitive; may be due to
cardiopulmonary source or invasive
procedures (diagnostic peritoneal
lavage, laparoscopy)
Evidence of diaphragmatic
injury
Nonspecific
Significant gastrointestinal
bleeding
Uncommon, unknown accuracy
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
Hemodynamic instability Major solid visceral or
vascular injury
Pitfall
Thorax or mediastinum,
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
hemorrhage
Proximal gut
Uncommon, unknown
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.
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2.
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4.
5.
Evisceration
Intraperitoneal air
Local wound exploration
Ultrasonography
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.
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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