Abd Trauma Flashcards
Types of abd injuries
Blunt vs. penetrating
- Integument
- MSK
- Splenic
- Hepatic
- Vascular
- GI tract
- GU/renal
- Pancreatic
Shock
- MC in trauma
hypovolemic/hemorrhagic
Shock
- hypovolemic / hemorrhagic pathophys
- Sympathetic and adrenal response: increase PVR and HR
- Vasoconstriction of skin, muscle, kidney, splanchnic = blood to heart and brain
- Pulse pressure narrows as lose more volume, leads to hypotension as compensatory mechanisms are overwhelmed
- Cells turn to anaerobic metabolism = lactic acid = acidosis
Hypovolemic or hemorrhagic shock
- Classification
- Class 1: <15% blood volume (750 mL)
- Class 2: 15-30% (800-1500 mL)
- Class 3: 30-40% (2000 mL)
- Class 4: >40%
Hypovolemic or hemorrhagic shock
- S/sx
- Tachycardia
- Blood pressure normal to hypotensive
- Pulse pressure: normal to narrowed
- Cap refill: normal to delayed
- Skin: cool, pale, cold, ashen
- Tachypnea
- May see decreased urine output
Hypovolemic or hemorrhagic shock
- Tx
- Stop hemorrhage
- Fluids
• Crystalloid if mild-moderate
• Blood transfusion if continued signs of hypoperfusion (fresh whole blood best): Type and cross match, if not avail use O-
• Vasopressors last resort
Tranexamic Acid (TXA)
- Stops bleeding
- Loading dose 1 g IV 100cc NS over 10 min
- Infusion: 1 G IV 250cc NS over 8 hours
FAST exam
Focused abdominal sonogram for trauma
- Looks for free fluid in the pericardial, pleural, and intraperitoneal spaces
- Visualize the heart, diaphragm, liver, spleen, and bladder: Morison’s pouch is located between R kidney and liver
Splenic Injury
- types
- Subcapsular hematoma
- laceration
- fracture
- avulsion
- Arterial extravasation (aka contrast blush or arterial bleeding)
Spleen fn
- Filtrate: particulate antigens, diseased cells, encapsulated organisms
- Immunologic: B lymphocyte reservoir, remove bacteria and ab, initiates immune reponse, produces ab (IgM)
Pitting: removal of nuclear remnants
Classification of splenic, hepatic, and renal trauma
1-5
1 is least bad
5 is worst
Splenic injury
- s/sx
- Hx consistent with splenic injury
- Nonspecific LUQ pain
- PE: LUQ tenderness and referred left shoulder pain (Kehrs sign)
- Mod decrease in bp, tachycardia, reduced H/H, increased WBC
Splenic Injury
- Dx
- US: FAST to look for free fluid and peri-capsular hematoma
- CT of abd and pelvis with contrast (CI if unstable with acute trauma)
Splenic injury
- Non-operative Tx
- Low grade injuries: minimal or no abd findings, hemodynamically stable, min lab evidence of blood loss, low E trauma, isolated injury on CT scan, no hilar involvement or massive disruption on CT
- ICU for 1-2 days, floor 2-5 days
- Serial H/H q 4 hr, decrease if stable
- Bedrest 48-72 hrs if H/H stable, then gradually increase while monitoring H/H
- If hemoglobin continues to drop after transfusion, consider sx
Splenic injury
- operative tx
- Splenorrhaphy: grade 1-2, usually only performed if already doing laparotomy for something else
- Partial splenectomy: grade 4, >30% of spleen must be preserved to maintain immunologic function
- Splenectomy: via open exploratory laparotomy/celiotomy
Splenic Injury
- Post-op complications
• MC atelectasis
• Also: pneumonia, pleural effusion, subphrenic hematoma/abscess, etc.
• Sepsis:
- Lose spleen = can’t mount immune response
- Vaccinations: Strep pneumonia, H. flu, meningitis prior to hospital discharge, booster in 5 years
- Education pts about risk, need to seek medical care if get fevers
Splenic injury and hepatic injury discharge/care instructions
- 8-12 weeks no physical activity that can cause blunt abd trauma
- Possible US at 8-12 weeks to eval healing process
- No pushing, pulling, lifting >5 lbs for 6-8 weeks
Hepatic Injury
- Overview
- MC in penetrating vs. blunt trauma
- Blunt trauma = more complex/likely to cause death
- Most death early post-op period dt shock and transfusion related coagulopathies
- Small to large increase in LFTs
- Big worry is coagulopathy
Hepatic Injury
- Dx
- CT scan of abd/pelvis with contrast
- Additional eval may be needed
- May need to do a diagnostic peritoneal lavage, if positive = surgery:
• Invasive
• Will be positive even if only a small amt of (maybe insignificant?) blood in peritoneal cavity
• Positive: 100,000 RBC, 500 WBC, bile, particulate matter, amylase>serum amylase, 10 mL gross blood aspirated
Hepatic Injury
- Tx
- Non-operative: Same as splenic injury
- Operative
• Prevent hypothermia and coagulopathies
• Keep warm and hydrated, don’t let them become hypovolemic!
• Techniques: Topical agents, hepatorrhaphy, cautery, manual compression, packing and drains, embolization of bleeding artery, etc.
Renal Trauma
- overview
- Blunt trauma accounts for 90%, penetrating 10%: Blunt associated with other intra-abd injuries 44% of the time
- Children prone to disruption of UPJ with rapid deceleration injuries secondary to hyperextension of spine
- Lacerations dt fractured ribs/transverse processes of lumbar spine
Renal trauma
- location of R and L kidney
- Right kidney: posterior to liver, close to colon and duodenum
- Left kidney: inferior to spleen, posterolateral to pancreas
Renal trauma
- Dx
- CT abd/pelvis with triple contrast (PO, IV, rectal)
- Arteriogram: if non-visualization of the kidney, can ID renal devascularization which indicates renal vascular injury
Renal Trauma
- s/sx
- Flank/upper abd tenderness
- Flank contusion/ecchymosis
- Lower rib fx
- Upper abd mass/fullness
- Crepitance over lower rib cage or lumbar area