8. Abdominal injuries

Question 1

Name ABSOLUTE Indications for transfusion of Packed red blood cells (PRBCs) in trauma (1)

Answer 1

Hb <80 g/L in anypatient

Question 2

Name RELATIVE Indications for transfusion of Packed red blood cells (PRBCs) in trauma (4)

Answer 2

• Hb <100 g/Lin a patient with known CV disease
• Suspected or known massive hemorrhage
• Persistent hypotension following 2 L of IV crystalloids
• Evidence of end-organ dysfunction 2° to hypoxia

Question 3

How to calculate total allowable blood loss?

Answer 3

Question 4

Name: Mechanism of Injury (2)

Answer 4

• Penetrating trauma
• Blunt trauma

Question 5

Describe mechanism of injury and name common injured organs: Penetrating trauma (2)

Answer 5

• Mechanism of Injury: Stab wounds; missile/gunshot wounds
• Commonly Injured Organs: Spleen, liver, pancreas, duodenum, small intestine, colon

Question 6

Describe mechanism of injury and name common injured organs: Blunt trauma (2)

Answer 6

• Mechanism of Injury: Motor vehicle/bicycle/all-terrain vehicle crash; auto vs. pedestrian injury; fall from height; child abuse
• Commonly Injured Organs: Spleen, liver, GU tract, pelvis

Question 7

Describe history: Abdominal injuries (2)

Answer 7

• It is important to establish the mechanism of injury and the prehospital treatment received (e.g., amount of fluids received, intravenous lines established) as well as the patient’s medical Hx.
• Injuries to the abdo viscera often produce nonspecific signs and symptoms, many of which take hours to days to develop.

Question 8

Describe physical exam: Abdominal injuries (5)

Answer 8

Every trauma patient should undergo a primary survey using the ABCDE algo- rithm followed by a secondary survey:

• Airway: if the patient is alert and conversant, then the airway is likely secured. Patients with significant facial bone trauma, upper airway burns, or deteriorating mental status (Glasgow Coma Scale ≤8) require intubation.
• Breathing: inspect the patient’s trachea and chest for signs of tension pneumothorax, flail chest, or open pneumothorax and manage immediately.
• Circulation: Assess for signs of hemorrhagic or cardiogenic shock. In the setting of hypotension and a positive FAST, urgent laparotomy is indicated.
• Disability: perform a neurologic examination and assess the patient’s level of consciousness and any focal neurologic signs.
• Exposure: remove patient’s clothing and carefully inspect for missed injuries. It is crucial to assess for blood on DRE as well as presence of tone. Prevent rapid heat loss with warming blankets and warmed intravenous resuscitation fluids. A tense and distended abdomen suggests increased intra-abdo pressure and may indicate a developing abdo compartment syndrome.

Question 9

Describe: FAST (2)

Answer 9

• Focused Assessment with Sonography for Trauma
• Assesses for free fluid in four areas— the four “Ps”: Perisplenic, Perihepatic, Pelvic, and Pericardial

Question 10

Name values for positive Diagnostic Peritoneal Lavage (DPL) (3)

Answer 10

• Gunshot = 5,000 RBC/mL
• Blunt= 100,000 RBC/mL
• Stabbing= 10,000 RBC/mL

Question 12

Name investigations for abdominal injuries (7)

Answer 12

• Vital signs monitored continuously.
• Routine blood work: CBC, electrolytes, and coagulation profile, cross-matched for several units of packed red blood cells. An arterial blood gas panel should also be obtained to assess for adequacy of the patient’s Resp function.
• Every female patient within childbearing age should have a b-hCG test to exclude pregnancy.
• Urinalysis should be obtained to rule out occult bleeding suggestive of kidney trauma.
• A FAST U/S study should be promptly obtained to assess the patient’s peritoneal cavity for free fluid.
• DPL may be considered in select patients.
• Depending on the mechanism of injury and pretest index of suspicion, the hemodynamically stable patient should undergo a CT scan of the head, neck, spine, chest, abdomen, pelvis, or extremities to exclude occult injury and prioritize the management approach.

Question 13

Describe: Diagnostic Peritoneal Lavage (5)

Answer 13

• Diagnostic Peritoneal Lavage
• It involves infusion and drainage of 1 L of saline into the abdomen, aspirating the fluid, and analyzing it for the number of red blood cells present.
• Like FAST, DPL does not localize the injury and cannot identify a retroperitoneal source of bleeding.
• Few, if any, level one trauma centers in Canada still use DPL.
• Decisions regarding operative versus nonoperative management are made based on clinical picture, FAST status, and CT findings.

Question 14

Describe management: Abdominal injuries (4)

Answer 14

• Urgent laparotomy in abdo trauma for certain patients
• Hemodynamically stable patients with a positive DPL, FAST, or CT scan but no indications for emergent laparotomy are candidates for a trial of nonoperative therapy with close monitoring and serial blood work and abdo exams.
• Most patients with blunt hepatic and splenic injuries are given a trial of nonoperative management.
• Patients with ongoing bleeding, particularly from a splenic injury, may require angiography with possible embolization. Other locations may include the liver or injured pelvic vessels

Question 15

Name Indications for urgent laparotomy in abdo trauma (7)

Answer 15

• Hemodynamically unstable patient with Abdo, back, or flank trauma
• Obvious evisceration
• Physical exam findings consistent with peritonitis
• Transabdominal gunshot wound
• Penetrating wound that extends through the fascia
• Free air present on either x-ray or CT
• Abdo organ injury as seen on CT that requires surgical repair.

Question 16

Name Causes of Hypotension in the abdo Trauma patient (6)

Answer 16

• Acute bloodloss/hemorrhagic shock
• Spinal shock
• Toxic ingestion
• Pregnancy
• Acute and chronic
• Resporcardiac disease

Question 17

Describe: Initial Tx of the abdo trauma patient

Answer 17