01-3 Trauma - Abd, Pelvic, GU Flashcards
A 19-year-old gang member is shot in the abdomen with a .38-caliber revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender.
Management. No diagnostic tests are needed. A penetrating gunshot wound of the abdomen gets exploratory laparotomy virtually every time. Preparations before surgery: an indwelling bladder catheter, a large-bore venous line for fluid administration, and a dose of broad-spectrum antibiotics.
At exploratory laparotomy for the patient described in the previous question, examination shows clean, punched-out entrance and exit wounds in the transverse colon.
If there is gross fecal contamination, do a colostomy. With minimal contamination, primary repair is okay.
A 19-year-old gang member is shot once with a .38-caliber revolver. The entry wound is in the left mid-clavicular line, 2 inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical examination is difficult to perform.
What is it? The point here is to remind you of the boundaries of the abdomen; although this sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line, though. Belly and chest are not stacked up like pancakes: they are separated by a dome. This fellow needs all the stuff for a penetrating chest wound (chest x-ray, chest tube if needed), plus the exploratory laparotomy.
A 42-year-old man is stabbed in the belly by a jealous lover. The wound is lateral to the umbilicus, on the left, and omentum can be seen protruding through it.
The general rule is that penetrating abdominal wounds get a laparotomy. That is true for gunshot wounds, but it is also true for stab wounds if it is clear that peritoneal penetration took place.
In the course of a domestic fight, a 38-year-old obese woman is attacked with a 4-inch-long switchblade. In addition to several superficial lacerations, she was stabbed in the abdomen. She is hemodynamically stable, and does not have any signs of peritoneal irritation.
This is probably the only exception to the rule that penetrating abdominal wounds have to be surgically explored—and that is because this in fact may not be penetrating at all! (The blade was short, the woman is well padded.) Digital exploration of the wound tract in the ER may show that no abdominal surgery is needed. But if there is any suspicion of intra-abdominal injury, obtain an abdominal CT.
I. A 31-year-old woman smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 75 over 55, with a pulse rate of 110, and a CVP of 0. On physical examination, she has a tender abdomen, with guarding and rebound on all quadrants.
II. A 31-year-old woman smashes her car against a wall. She has multiple injuries including upper and lower extremity fractures. Her blood pressure is 135 over 75, with a pulse rate of 82. On physical examination she has a tender abdomen, with guarding and rebound on all quadrants.
What is it? Solid organs will bleed when smashed. Hollow viscera will spill their contents. Often they both happen, but one can exist without the other. Here we have two vignettes with plenty of clues to suggest that “evil fluid” is loose in the belly. In one case there is also bleeding, in the
other there is not; but the presence of “acute abdomen” after blunt abdominal trauma mandates laparotomy. They will both need it.
A 26-year-old woman has been involved in a car wreck. She has fractures in both upper extremities, facial lacerations, and no other obvious injuries. Chest x-ray is normal. Shortly thereafter she develops hypotension, tachycardia, and dropping hematocrit. Her CVP is low.
What is it? Obviously blood loss, but the question is where. The answer is easy: it has to be in the abdomen. To go into hypovolemic shock one has to lose 25 to 30% of blood volume, which in the average size adult will be nearly 1.5 L (25 to 30% of 5 L). In the absence of external hemorrhage (scalp lacerations can bleed that much), the bleeding has to be internal. That much blood cannot fit inside the head, and would not go unnoticed in the neck (huge hematoma) or chest (a good decubitus x-ray can spot anything greater than 150 ml, and even in other
positions 1.5 L would be obvious). Only massive pelvic fractures, multiple femur fractures, or intraabdominal bleeding can accommodate that much blood. The first two would be evident in physical examination and x-rays. The belly can be silent. Thus the belly is invariably the place to look for that hidden blood.
Diagnosis. We have a choice here. The old, invasive way was the diagnostic peritoneal lavage. The newer, noninvasive ways are the CT scan or sonogram. CT scan is best, but it cannot be done in the patient who is “crashing.”
Management. Most likely finding will be ruptured spleen. If stable, observation with serial hemoglobin and hematocrit levels every 6 hours for 48 hours. If not, exploratory laparotomy.
A 27-year-old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest x-ray shows fractures of the 8th, 9th, and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128, which do not respond satisfactorily to fluid and blood administration. He has a positive peritoneal lavage, and at exploratory laparotomy a ruptured spleen is found.
What is it? You are unlikely to be asked technical surgical questions, but when dealing with a ruptured spleen, an effort will be made to repair it rather than remove it; in children the effort will be even greater. But if the vignette says that the spleen had to come out, then further management includes administration of Pneumovax and also immunization for Haemophilus influenza B and meningococcus.
A multiple trauma patient is receiving massive blood transfusions as the surgeons are attempting to repair many intraabdominal injuries. It is then noted that blood is oozing from all dissected raw surfaces, as well as from his IV line sites. His core temperature is normal.
Signs of coagulopathy in this setting require a shotgun approach to treatment. Empiric administration of both fresh-frozen plasma and platelet packs is recommended, roughly 10 units of each.
During the course of a laparotomy for multiple trauma the patient develops a significant coagulopathy, a core temperature below 34°C, and refractory acidosis.
This combination of hypothermia, coagulopathy, and acidosis requires that the abdomen be closed immediately and no further operating be done (not even a formal abdominal closure). The standard approach is to pack all bleeding surfaces and close the abdomen temporarily.
An exploratory laparotomy for multiple intraabdominal injuries has lasted 3.5 hours, during which time multiple blood transfusions have been given, and several liters of Ringer lactate have been infused. When the surgeons are ready to close the abdomen they find that the abdominal wall edges cannot be pulled together without undue tension. Both the belly wall and the abdominal contents seem to be swollen.
This is the so-called abdominal compartment syndrome. All the fluid that has been infused has kept the patient alive, but at the expense of creating a lot of edema in the operative area. Forced closure would produce all kinds of problems. The bowel cannot be left exposed to the outside either, so the standard approach is to close the wound with an absorbable mesh over which formal closure can be done later, or with a nonabsorbable plastic cover that will be removed later.
In the first postoperative day, a trauma patient develops a very tense and distended abdomen, and the retention sutures are cutting through the abdominal wall. He also develops hypoxia and renal failure.
This is also the abdominal compartment syndrome that was not obvious at the end of the operation, but has developed thereafter. The abdomen will have to be decompressed by opening the incision and using a temporary cover as described above.
In a rollover car accident, a 42-year-old woman is thrown out of the car, and subsequently the car lands on her and crushes her. At evaluation in the ER it is determined that she has a pelvic fracture. She arrived hypotensive, but
responded promptly to fluid administration. CT scan shows no intraabdominal bleeding, and a pelvic hematoma.
Nonexpanding pelvic hematomas in a patient who has become hemodynamically stable are left alone. Depending on the type of fracture, the orthopedic surgeons may eventually do something to stabilize the pelvis, but at this time the main issue is to rule out the potential associated pelvic injuries: rectum, bladder, and vagina. Physical examination and a Foley catheter will do it.
In a rollover car accident, a 42-year-old woman is thrown out of the car, and subsequently the car lands on her and crushes her. At evaluation in the ER it is determined by physical examination that she has a pelvic fracture. She
arrived hypotensive and did not respond to fluid resuscitation. Hemodynamic parameters have continued to deteriorate. Sonogram performed at the ER shows no intraabdominal bleeding.
A tough situation. People can bleed to death from pelvic fractures, and thus it seems that we ought to do something about it. But that is easier said than done. Surgical exploration is not the answer; these injuries are typically not in the surgical field afforded by a laparotomy. Ateriographic evaluation might reveal arterial bleeding amenable to embolization. Angiographic therapy is not
effective for venous bleeding. External pelvic fixation might be the only helpful intervention. A reasonable sequence to give in the examination, as the answer to this vignette, would be external pelvic fixation first, followed by a trip to the angiography suite (interventional radiology) for possible angiographic embolization of both internal iliac arteries.
I. A young man is shot point blank in the lower abdomen, just above the pubis. He has blood in the urine, and no evidence of rectal injury.
II. A woman is shot in the flank, and when a Foley catheter was inserted in ER, the urine was found to be grossly bloody.
The hallmark of urologic injuries is blood in the urine after trauma. These two are clear-cut. The therapy is also clear. Penetrating urologic injuries are like most penetrating injuries elsewhere: they need surgical repair.
