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Rosens > 38. Abdo Trauma > Flashcards

38. Abdo Trauma Flashcards

1
Q

Most likely organs to sustain penetrating trauma?

A

sm intest
colon
liver

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2
Q

MC organ injured in blunt trauma?

A

splen
liver second

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3
Q

What is the anterior abdomen?

A

region between anterior axillary lines from costal margins to groin creases

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4
Q

Low chest defn

A

nipple line or 4th ICS ant, inferior scapula tip or 7th IC posteriorly and extends down to inferior costal margins

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5
Q

Flank defn

A

ant and posterior axillary lines bilaterally inf scapula to tip of iliac crest

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6
Q

Gun shot wounds - what is the concerning physicss of E?

A

= 700mv^2/ 2 ga (ga = gravit accel)

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7
Q

Gun shot wounds - high vs low velocity impact?

A

low <1100 ft/s high - faster than 2000-2500

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8
Q

Most important determinations of firearm injuries?

A

distance firearm and victim
muzzle v
characteristics of projectile

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9
Q

Shotgun wounds vs other projectile injuries

A

type of shot and distance from the victim

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10
Q

Seat belt injuries - hoe fo these occur?

A

compression bowel between belt and VC- contusion or perforation or intestines or mesentary tear

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11
Q

What is the seat belt sign?

A

contusion along lower abdomen - high correlation with intraperitoneal pathologic lesions

recommended further imaging

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12
Q

What is helpful to gauge severity of injury in penetrating abdo trauma/stab wounds:

A

number
type and size
instrument
posture of victim relative to direction of assault
EBL
time of injury
response to fluids

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13
Q

Triad of injuries to what areas is concerning for pathologic lesions?

A

torso
cranium
lower extremity

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14
Q

Uunexplained hypotension accompanies signifi- cant blunt trauma, one should assume the presence of..

A

intraperitoneal hemorrhage

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15
Q

Gray Turner signs

A

ecchymotic discoloration of the flanks

= retroperitoneal hemorrhage

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16
Q

Cullen sign

A

umblicus ecchymotic discoloration

= retroperitoneal hemorrhage

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17
Q

Overall, the accuracy of the physical examination in patients with blunt abdominal trauma is only _% - % because the initial presentation may be deceptively benign

A

55% to 65%

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18
Q

DDX from abdo trauma:

A

solid or viscous organ injury, vascular injuries, intra-abdominal bleed- ing, abdominal compartment syndromes (ACSs) or retroperitoneal hematomas. Injury to the abdominal aorta can result in mortality up to 50% to 70%

19
Q

The hematocrit can represent a baseline value but is also a function of the extent of and time from hemorrhage, exogenous fluid adminis- tration, and endogenous plasma refill. How is this helpful?

A

Patients with hemorrhagic shock (at least 40%) demonstrate much faster plasma refill rates, with significant decreases in hematocrit within 90 minutes. Hematocrit val- ues often represent a conundrum when viewed in isolation but are use- ful when measured serially.

20
Q

Labs for abdo trauma

A

cbc
vbg-lactate
LE
etoh

*lipase no longer helpful

21
Q

When is AXR useful in blunt abdo trauma?

A

free intraperitoneal air
FB and projectiles

22
Q

limitations of abdo CT - which organs?

A

pancreas
diaphragm
small bowell
mesentary

23
Q

Placement of an __gastric tube is preferable in patients with midface or skull base fractures.

A

oro

24
Q

Alternative for an ED thoractomy?

A

REsus endovascular balloon occlusion (REBOA)

25
Q

Perforated hollow viscous injuries - abx?

A

piperacillin-tazobactam 3.375 g intravenously, is recommended in the setting of perforated hollow viscus injuries.

26
Q

Penetrating anterior abdo trauma: Emergent laparotomy indications:
4

A
  1. HD compromise
  2. Peritoneal signs
  3. Evisceration
  4. L sided diaphragm injury
27
Q

Penetrating injuries: laparotomy only considered with what additional clinical evidence: 3

A
  1. with gastric hemorrhage from NG tube
  2. implements in situ
  3. intraperitoneal air
28
Q

If clinical indications for lap from penetrating trauma are absent: assess wound itself: indications for lap? 5

A
  1. eviceration of bowel/omentum
  2. intraperitoneal free air on CXR
  3. Local wound exploration: unclear if small puncture, long tangential wund, multiple wound or obese
  4. U/s - efast +
  5. Lap or thoracoscopy in OR for LWE
29
Q

Equivoval signs of diaphragmatic injury - how to manage?

A

these can be difficult to see
consider OR f/u

30
Q

What is renal injury imaging of choice in penetrating injury?

A

CT with IV contrast

31
Q

3 signs in penetrating injury a patient should be taken for urgent lap

A

If the patient is hemodynamically unstable, has peritonitis, or has an unreliable abdominal exam, the patient is taken for emergent laparotomy.

32
Q

The decision to perform immediate laparotomy after injury from a blunt mechanism is reserved for patients with the following findings: 3

A
  1. Refractory hypotension in a patient with positive e-FAST examina-
    tion for hemoperitoneum and absence of an unstable pelvic fracture
  2. Obvious peritonitis with positive e-FAST examination
  3. Evidence on e-FAST of intra-abdominal injury in the context of
    other life-threatening injuries, such as uncontrollable chest hemorrhage, which require transfer to the operating room
    In patients who are hemodynamically stable, CT scanning is the
    diagnostic modality of choice, as outlined earlier.
33
Q

Clinical indicationsc for laparotomy after blunt trauma - 5

A

unstable VS with strongly suspected abdo injury
unequivocal peritoneal irritation
pneumoperitoneum
evidence of diaphragmatic injury
sign GIB

34
Q

Pelvic fracture: lap vs observe

A

pelvic # - HD unstable, fast +

if angio shows IP injury

35
Q

Combined abdo trauma and blunt head trauma algorithm: management

A

airway and ICP manage
HD unstable with IPH/+ fast - Lap consideration prior to head ct if no lateralizing signs vs head ct and cranio consideration

HD stable: check for laterliing signs and consider head ct/cranio if +, if negatvie can abdo CT

36
Q

Combination wide mediastinum, blunt abdo trauma algorithm: how to manage?

A

wide mediastinum - initial resus
HD unstable: yes - look for intraperitoneal hemorrhage sign or + fast and lap with intraop TEE/AG

if not HD unstable - ct chest and abdo

37
Q

What is REBOA for?

A

performed at bedside to decr ongoing intra-abdo or pelvic exsanguination while increasing proximal perfusion pressure

38
Q

How to place REBOA device?

A

access proximal to femoral a
balloon adv to thorax in distal subclavian for intraabdo bleed or inferior to renal a for pelvic bleeding

39
Q

When to use therapeutic angiography for abdo injury?

A

unstable pt with blunt trauma and pelvic - when can see vessels
-consideration for splenic injuries

40
Q
  1. The extended focused assessment with sonography for trauma (e-FAST) scan of a patient with blunt abdominal trauma shows a hypoechoic stripe in the pouch of Douglas. Which of the following is correct?
    a. In the presence of hemodynamic instability, this indicates a need for laparotomy.
    b. The patient needs to go for emergent laparotomy immediately.
    c. The patient requires repeat abdominal examinations and FAST
    examinations in the emergency department (ED).
    d. There is at least 500 mL free fluid in the abdomen.
    e. This indicates a ruptured bladder.
A

A

41
Q

. An 18-year-old man presents after a high-velocity front-end vehicle collision. He has a blood pressure of 90/70 mm Hg, heart rate of 120 beats/min, respiratory rate of 17 breaths/min, and a Glasgow Coma Score (GCS) of 13. On physical examination, he has a tender abdomen and an unstable pelvis. An extended focused assessment with sonography for trauma (e-FAST) examination is positive for free fluid in the abdomen. What should be the patient’s disposition? a. Admission to the trauma service for observation
b. Emergency department (ED) observation for 12 hours with repeat FAST examinations
c. Interventional radiology for pelvic angiography and emboliza- tion
d. Operating room for emergency laparotomy

A

D

42
Q
  1. A 27-year-old male presents 4 hours after an isolated stab wound
    to the anterior abdomen. His vital signs are heart rate 84 beats/min and blood pressure 115/64, and the lactate level is 0.9 mg/dL. His extended focused assessment with sonography for trauma (e-FAST) examination is negative for free fluid. He denies alcohol and drug use and appears clinically sober. Which of the following statements regarding this patient’s subsequent management is true?
    a. A negative computed tomography (CT) scan rules out the need for further evaluation.
    b. If local wound exploration (LWE) definitively demonstrates that the wound does not violate the peritoneum, the patient can be discharged from the emergency department (ED).
    c. The negative e-FAST examination rules out intra-abdominal injury requiring operative intervention.
    d. The patient meets criteria for emergent laparotomy.
A

B

43
Q
  1. Which of the following statements regarding splenic injuries in blunt abdominal trauma is true?
    a. A computed tomography (CT) scan with a grade IV splenic lac-
    eration indicates the need for laparotomy.
    b. Angiographic embolization has no role in high-grade splenic
    lacerations.
    c. Bedside extended focused assessment with sonography for
    trauma (e-FAST) can accurately rule-out splenic injury.
    d. CT scanning followed by serial abdominal examinations and hematocrits is a reasonable management option for certain
    splenic injuries at experienced centers.
    e. Mononucleosis increases the risk of splenic laceration from
    seemingly minor blunt abdominal trauma.
A

d

44
Q
  1. A 67-year-old female who is taking warfarin for atrial fibrillation
    presents after a high-mechanism motor vehicle collision. Her heart rate is 142 beats/min and blood pressure is 84/40 after 1 L of normal saline. Her Glasgow Coma Score (GCS) is 6, and her left pupil is 6 mm versus 3 mm on the right. Her physical examination is notable for a seat belt sign on the abdomen. Which of the following is not an acceptable approach to her initial assessment and treatment?
    a. Perform an extended focused assessment with sonography for trauma (e-FAST) examination to evaluate for the presence of intra-abdominal fluid.
    b. Perform chest and pelvic radiographs in the resuscitation bay.
    c. Perform empirical craniotomy concurrently with laparotomy in the operating room after a positive diagnostic peritoneal aspira-
    tion.
    d. Perform endotracheal intubation and begin mild hyperventila-
    tion.
    e. Proceed to radiology for an emergent abdominal computed
    tomography (CT) scan.
A

e

Rosens (40 decks)

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