3 - Abdominal Trauma Flashcards
Abdominal trauma accounts for?
15-20% of all trauma deaths
You survived the initial abdominal injury, now what kills you?
Sepsis
MCC of blunt abdominal trauma?
MVC
Falls can do it too
Typical blunt intra-abdominal trauma is?
Hollow viscous rupture
Penetrating abdominal injury considerations?
Bullets:
- cavitation injury
- secondary missiles (bone etc)
Stab/FOB:
- length, trajectory and frag may be ukn during initial eval
Assume penetrating abdominal trauma with:
Any injury to:
- lower chest
- pelvis
- flank
- back
Is considered penetrating injury until proven otherwise
Problem with abdominal injuries (and really most inj) with young healthy pts?
They compensate for intra-abdominal hemorrhage before clinical signs become overt
They compensate, compensate, compensate, die
Symptoms of abdominal contusion?
Pain w flexion, rotation
Focal tenderness
Hematoma
- Palpable mass inferior to umbilicus
S/s of solid organ damage?
Gen due to blood loss
- increase in pulse pressure
- pain and bleeding may be minimal
- delayed rupture is a thing with liver and spleen
= 15% blood loss presentation?
Can have increased pulse pressure as the only clue
- be cautious w sig MOI and increased pulse
Spleen and liver inj presentation?
Spleen - may refer to L shoulder/arm
Liver - may refer to right shoulder
What is a condition that predisposes people to splenic inj?
Pregnancy
Mononucleosos
Bicycles
In blunt abd trauma, 5% incidence of?
Blunt bowel and mesenteric injuries
Hollow viscus injuries produce what symptoms?
Combination of:
- blood loss
- peritoneal contamination w/ GI contents
Hemorrhage from mesenteric inj?
May be minimal and easily missed on PE
Chemical irritation of peritoneum presentation?
Gastric acid contents may produce:
- immediate pain
- But bacterial contamination may delay s/s
- delays increase mortality
Previlence of pancreatic injuries?
4% of abd trauma
- but sig morbidity and mortality
S/s of pancreatic inj?
No specific but look for:
- MOI - rapid deceration
- no seatbelt, bicycle handle bars
Duodenal inj?
Relatively asymptomatic
- small hematoma of duodenum may go undiagnosed
- gastric outlet obstruction developes as it expands
When to consider duodenal rupture?
High-veolicity deceleration events where intraluminal pressure of pylorus and proximal small bowel rapidly increases
Delayed presentation of duodenal rupture?
Fever and leukocytosis herald the development of sepsis
What happens when you knock the wind out of a pt?
Diaphragm spasms (2/2 blow to epigastrium)
- difficulty breathing
- diaphragm cannot relax
- lungs cannot expand
- relaxes slowly
Diaphragmatic rupture
Rare (0.8-5%) of pts with thoracoabdominal inj
- left sided phenomenon
What if you miss a diaphragmatic injury?
May lead to:
- delayed herniation
- strangulation of abdominal contents through defect
How are intra-abdominal injuries diagnosed?
No gold standard but: - PE - Lab analysis - Imaging - Repeated exams (The cost of missing one is high, so be careful)
US on abdominal trauma?
FAST
- rapid identification of free intraperitoneal fluid in the hypotensive pt w blunt abdominal trauma
Advantages of FAST?
Accurate Rapid (<4min) Noninvasive Repeatable Portable No nephrotoxic or ionizing exposure
Massive hemoperitoneum can be quickly identified by looking in? (FAST)
Morrison’s pouch
82-90% of hypotensive pts
Advantage of FAST over diagnostic peritoneal lavage (DPL)
Fast evaluates for
- free pericardinal/pleural fluid
- pneumothorax
Limitation of FAST vs CT?
CT can id exact source of free intraperitoneal fluid
- may change w adoption of contrast enhanced US (sounds fancy)
CT can eval retroperitoneum better
So consider FAST and CT complementary rather than competing
Disadvantages of FAST?
Operator-dependent nature of exam
difficult in:
- obese
- sub Q air
- excessive bowel gas
Cannot differentiate between intraperitoneal hemorrhage and ascites
Uses for US other than FAST?
Guide suprapubic catheter placement
Measure inferior vena cava diameter
- marker of intravascular volume
- predictor of mortality
Because FAST can detect small amounts of free intraperitoneal fluid it can?
Estimate rate of hemorrhage through serial exams
A positive DPL in isolation is no longer
Absolute indication for exploratory laparotomy
Noninvasive gold standard study for diagnosis of abdominal injury?
Abdominopelvic CT w IV contrast
Advantages of CT for abdominal trauma?
Precise locations and grade of inj can be id’d
Quantify and differentiate amount and type of free fluid in abdomen
Eval retroperitoneal inj
- makes it ideal for duodenum and pancreas
Disadvantages of CT?
Ionizing radiation
Must leave trauma bay
Locally explore anterior abd stab wounds to
Assess for violation of peritoneum
Gold standard therapy for significant intra-abdominal injuries?
Laparotomy
- rarely misses an inj
- allows for complete eval
Who needs surgical exploration?
All pts w
- persistent HOTN,
- abdominal wall disruption
- peritonitis
Absolute indications for laparotomy
- blunt trauma
- Anterior abdominal inj w HOTN
- Abdominal wall disruption
- Peritonitis
- Free air under diaphragm
- Pos FAST/DPL in hemodynamically unstable pt
- CT says you need it
Absolute indications for laparotomy
- penetrating inj
- Inj to abdomen, back, flank w HOTN
- abd tenderness
- GI evisceration
- high suspicion for abd GSW
- CT says you need it
Relative indications for laparotomy
- blunt trauma
- Pos FAST/DPL in hemodynamically stable pt
- solid visceral inj (stable pt)
- hemoperitoneum on CT w/o clear source
Relative indications for laparotomy
- penetrating trauma
Pos local wound exploration after stab wound
Ct can grade visceral injuries, how does this predict success
CT grading may not agree w intraoperative observation and does not always predict the success of nonoperative management
WTF is REBOA?
Resuscitave endovascular balloon occlusion of the aorta
- endovascualr balloon occlusion of the aorta
REBOA is a percutaneous method to?
- Achieve temp occlusion of aorta
- Maintain/increase perfusion to heart and lungs in setting of shock
- Avoid thoracotomy for proximal aorta control
For the purposes of REBOA, how is the aorta divided?
3 zones
- I: descending thoracic aorta (between origin of L subclavian and celiac arteries)
- II: between celiac and lowest renal artery
- III: lowest renal artery and aortic bifurcation
How long can REBOA be left in?
60 min is tolerated well and recoverable
Return instructions for abd inj?
If you develop:
- fever
- vomiting
- increased pain
- blood loss s/s
Return promptly to ED
What do you call cheese that is not yours?
Nacho Cheese
