Abdo Trauma Flashcards
Indications for immediate laparotomy in blunt abdo trauma:
- Hypotensive and + eFAST
- Frank peritonism
- HD instability despite replacement
- Free gas on XR
- Ruptured diaphragm
PLUS IF PENETRATING:
- Stab wound with:
–> Peritoneum breached
–> Evisceration
–> GI haemorrhage
–> Weapon in situ
- Gun shot (any)
FAST TECHNIQUE:
https://www.pocus101.com/efast-ultrasound-exam-made-easy-step-by-step-guide/
Technique: RUQ view in eFAST:
Cardiac probe
Marker to head
Midaxillary
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Identify liver, kidney, diaphragm and pleural space. Slide up/ down 1 space PRN.
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1- Hepatorenal angle (Morrison’s Pouch)
–> Fluid usually seen here
2- Subphrenic
3- Pleural
Then back down to complete full window by seeing:
4- Inferior pole kidney
Technique: LUQ view in eFAST:
Marker to head
‘Knuckles to bed*
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Same as RUQ
–> Will look the same on screen
–> Same views
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…but fluid usually seen subdiaphragmatic (ligament limits tracking around kidney)
Technique: Pelvic view in eFAST:
Marker to head
Midline
Tilt down, ‘fan’ L - R
Try for full bladder
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Identify:
Bladder
Uterus or Prostate (+seminal vesicles)
Rectum
MALE: Rectovesical space
or
FEMALE: Pouch of Douglas (rectouterine)
–> Trace fluid here physiological
THEN
Tilt 90deg to also examine in Transverse
Indicator to patient right
Technique: Cardiac view in eFAST:
Marker to right
Subxiphoid
1- Pericardial effusion
2- Gross look at heart:
–> Systolic function
–> Tamponade phys (RV collapse)
–> Obvious valve incompetence etc.ark
Technique: Pleural view in eFAST:
Marker to head
Midaxillary
Identify:
- 2 rib shadows
- B mode: ants
- M mode: Seashore / barcode
*‘Lung point sign’ in either mode
DPL technique:
Risk of unnecessary laparotomy: identifying small bleeds that don’t need OT
- Insert needle 2cm below umbilicus
- 10ml blood asp = diagnostic
- Otherwise:
–> Seldinger
–> Infuse 1L (10ml/kg) saline
–> Drain back out
–> Send for analysis = >100k RBC per ml = diagnostic.
Abdominal compartment syndrome?
>20mmHg (20 kids) and new organ dysfunction
CAUSES
< Abdo wall compliance: obese, lung hyperinflation, prone
> Abdominal contents: ileus, ascites
Post surgical
DIAGNOSIS
- Bladder pressure
MANAGEMENT
- Compliance: Semi upright, reduce lung hyperinflation, paralyse
- Contents: NGT, aspirate ascites, prokinetics
- Avoid excess fluids
AAST grades of LIVER injury:
GRADE 1:
- SC haematoma <10% SA
- Capsule lac <1cm deep
GRADE 2
- SC haematoma 10-50%
- Capsule lac 1-3cm deep and <10cm long
- IP haematoma <10cm
GRADE 3
- SC haematoma >50%
- Capsule lac >3cm
- IP haematoma >10cm or ruptured
- Any ruptured haematoma
- CONTAINED active bleeding
GRADE 4
- FREE active bleed into peritoneum
- Lobe disrupted 25-75%
GRADE 5
- Lobe disrupted >75%
- Hilar vascular injury (juxtahepatic)
GRADE 6
- Liver avulsion
ADVANCE ONE GRADE FOR MULTIPLE INURIES UP TO GRADE 3
Complications of liver trauma
Haemorrhage
Delayed/ secondary haemorrhage
Liver infarct
Bile leak
Biloma
Bile fistula
Hepatic artery aneurysm
AAST grading of SPLENIC injury:
Similar, but slightly different to liver
GRADE 1
- SC haematoma <10%
- Capsule lac <1cm
GRADE 2
- SC haematoma 10 - 50%
- Capsule lac 1-3 cm
- IP haematoma <5cm
GRADE 3
- SC haematoma >50%
- Capsule lac >3cm
- IP haematoma >5cm
GRADE 4
- CONTAINED active bleeding
- >25% devascularisation
GRADE 5
- Shattered
-FREE active bleed into peritoneum
Which liver/ splenic injuries require intervention?
CLINICAL picture, NOT GRADE.
ANY grade with active, significant bleeding (eg. hypoTN, Hb dropping, blush on CT) requires intervention.
Stable-ish –> Embolisation
Unstable –> Laparotomy
If stable, can just watch. Regardless of grade.
Role of LFTs in blunt abdominal trauma?
Transaminitis occurs in liver injuries.
Not very specific, but is sensitive- worth checking.
Does a normal lipase rule out pancreatic trauma?
NO- can be normal initially and rise later.
What does this CT show? Significant in context blunt abdo trauma:
Pneumo-retroperitoneum
Breach of gas-filled RP structure:
- Duodenum
- Asc or desc colon
- Rectum
AAST grading of RENAL injury:
GRADE 1
- SC haematoma
- Contusion
BUT no laceration
GRADE 2
- Lac <1cm deep
- No urinary extravasation
- Contained perirenal haematoma (within perirenal fascia)
GRADE 3
- Lac >1cm deep
- No urinary extravasation
- Actively bleeding perirenal haematoma (within fascia)
GRADE 4
- Laceration involving renal pelvis
- Urinary extravasation
- Segmental infarct (clot)
- FREE active bleeding
GRADE 5
- Shattered
- Avulsed
ADVANCE A GRADE FOR MULTIPLE INJURIES, UP TO GRADE #
