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ER 2 > Abd Trauma > Flashcards

Abd Trauma Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Types of abd injuries

A

Blunt vs. penetrating

  • Integument
  • MSK
  • Splenic
  • Hepatic
  • Vascular
  • GI tract
  • GU/renal
  • Pancreatic
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2
Q

Shock

- MC in trauma

A

hypovolemic/hemorrhagic

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3
Q

Shock

- hypovolemic / hemorrhagic pathophys

A
  • 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
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4
Q

Hypovolemic or hemorrhagic shock

- Classification

A
  • Class 1: <15% blood volume (750 mL)
  • Class 2: 15-30% (800-1500 mL)
  • Class 3: 30-40% (2000 mL)
  • Class 4: >40%
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5
Q

Hypovolemic or hemorrhagic shock

- S/sx

A
  • 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
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6
Q

Hypovolemic or hemorrhagic shock

- Tx

A
  • 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
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7
Q

Tranexamic Acid (TXA)

A
  • Stops bleeding
  • Loading dose 1 g IV 100cc NS over 10 min
  • Infusion: 1 G IV 250cc NS over 8 hours
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8
Q

FAST exam

A

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
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9
Q

Splenic Injury

- types

A
  • Subcapsular hematoma
  • laceration
  • fracture
  • avulsion
  • Arterial extravasation (aka contrast blush or arterial bleeding)
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10
Q

Spleen fn

A
  • 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
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11
Q

Classification of splenic, hepatic, and renal trauma

A

1-5
1 is least bad
5 is worst

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12
Q

Splenic injury

- s/sx

A
  • 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
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13
Q

Splenic Injury

- Dx

A
  • US: FAST to look for free fluid and peri-capsular hematoma

- CT of abd and pelvis with contrast (CI if unstable with acute trauma)

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14
Q

Splenic injury

- Non-operative Tx

A
  • 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
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15
Q

Splenic injury

- operative tx

A
  • 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
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16
Q

Splenic Injury

- Post-op complications

A

• 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

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17
Q

Splenic injury and hepatic injury discharge/care instructions

A
  • 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
18
Q

Hepatic Injury

- Overview

A
  • 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
19
Q

Hepatic Injury

- Dx

A
  • 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
20
Q

Hepatic Injury

- Tx

A
  • 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.
21
Q

Renal Trauma

- overview

A
  • 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
22
Q

Renal trauma

- location of R and L kidney

A
  • Right kidney: posterior to liver, close to colon and duodenum
  • Left kidney: inferior to spleen, posterolateral to pancreas
23
Q

Renal trauma

- Dx

A
  • 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

24
Q

Renal Trauma

- s/sx

A
  • Flank/upper abd tenderness
  • Flank contusion/ecchymosis
  • Lower rib fx
  • Upper abd mass/fullness
  • Crepitance over lower rib cage or lumbar area
25
Q

Renal Trauma

- lab

A

hematuria

26
Q

Renal Trauma

- Tx

A
  • Minor (grade 1-2) are 70%, do not require intervention
  • Major (grade 3-4) are 10-15%, management depends on clinical status and other associated injuries
  • Grade 5 are 10-15%, require immediate sx to control life threatening bleeding, often result in nephrectomy
  • Large devascularized segements may result in partial or complete nephrectomy
  • Absolute indication for further exploration: persistent bleeding, expanding/pulsatile hematoma, hemodynamically unstable, grade 5
  • Relative indication for further exploration: urinary extravasation of contrast from the bladder, devitalized segment, arterial thrombus
27
Q

Renal Trauma

- Post-op care

A
  • Watch for HTN and persistent hematuria
  • Closed suction drains
  • Monitor H/H and BUN/Cr
28
Q

Urinary Bladder Trauma

- overview

A
  • > 85% with bladder rupture have other serious injuries, mortality rate 22-60%
  • 85% also have pelvic fractures
  • Rarely cause hemodynamic instability alone
  • Blunt causes 75% of bladder trauma
29
Q

Urinary Bladder Trauma

- Contusion

A
  • Bladder wall hematoma or mucosal disruption without loss of wall continuity or extravasation
  • Dx: based on mechanism, hematuria, neg dx eval for rupture
30
Q

Urinary Bladder Trauma

- Rupture types

A
  • Extraperitoneal: complete disruption of bladder wall into extraperitoneal space, usu at lateral bladder or at base
  • Intraperitoneal: Complete disruption of bladder wall, usually dome of bladder, extravasation of urine into peritoneal cavity
  • Combined: both
31
Q

Urinary Bladder Trauma

- dx

A
  • Hx and PE. 98% have gross hematuria, complain inability to urinate, suprapubic pain
  • Abd exam: TTP, ecchymosis, edema, pelvic instability
  • GU/perineum exam: ecchymosis, edema, hematoma, urethral meatus blood: vaginal exam to rule out concomitant vaginal or urethra injury, or retained tampon
  • Rectum: may reveal bleeding or high riding prostate. MUST perform before foley cath placement
32
Q

Urinary bladder trauma

- Imaging

A
  • Retrograde urethrogram (RUG)
    • Perform if blood at urethral meatus or perineal ecchymosis, if catheter cannot be passed or high riding prostate
  • CT cystogram
    • MC used
    • Eval of other intra-abd injuries as well as bladder injuries
33
Q

Urinary bladder trauma

- Tx

A
  • catheter drainage

- Exploration, cystostomy, debridement and primary repair

34
Q

Urethral Injuries

A
  • NO FOLEY if suspect urethral injury or there is blood in the meatus
  • MC dt straddle injury
  • Urologist consult
35
Q

Scrotal Injuries

A
  • Laceration = urology consult

- US to r/o torsion or epididymitis and/or rupture of testicle

36
Q

Abdominal vascular injuries

A
  • Renal, hepatic, splenic, superior mesenteric artery, IVC, abdominal aorta, iliac vessels
  • Need vascular or trauma surgeon
  • Large amts blood products, platelets, fresh frozen plasma
  • Aggressive resuscitation
37
Q

Small Bowel Injuries

A
  • Seat belt contusion: worry about SM injury
  • Penetrating GSW cause 80%, stab wounds cause 20%
  • Blunt trauma 5-15%
  • All GSW to abdomen = celiotomy
  • Ct/US not reliable to ID hollow viscous injury unless lots of free air or intraperitoneal fluid
38
Q

Small bowel injuries

- tx

A
  • Minor: simple sutures

- Major: resection and primary anastomosis

39
Q

Colon Injuries

A
  • Occur in 15-40% penetrating abd wounds
  • Blunt trauma rare, from blowout injuries from seatbelts in MVC
  • CT scan of abdomen and pelvis with rectal contrast can help (CT not helpful for hollow viscous injury)
  • Free air on radiographic studies
  • Tx: primary repair, resection, anastomosis, colostomy
40
Q

Pancreatic Injury

A
  • Occur in 3-10% abdominal injuries, 2/3 dt penetrating trauma
  • US and CT may be helpful to ID
  • Grading: 1 least bad, 5 worst
  • ERCP: evaluate ductal system, is invasive
  • MRCP: not as sensitive but not invasive
  • Tx: control hemorrhage, debride de-vascularized pancreas, JP drainage, pancreatectomy, jejunostomy
  • Octreotide: decrease output from pancreatic fistulas
  • Whipple: if transection of pancreatic head
41
Q

Gastric Injury

A
  • Occur in 7-20% of penetrating abd trauma, blunt trauma rare
  • Free air indicative of perforation
  • 98% can be tx with debridement and primary repair
  • May need wound vac until edema subsides (also small bowel)

ER 2 (10 decks)

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