Abdominal and pelvic trauma Flashcards
Thoracoabdomen organs at risk
Diaphragm
Liver
Spleen
Stomach
“Flank” boundaries
Anterior axillary line
Posterior axillary line
Sixth intercostal space superiorly
Iliac crest inferiorly
“Back” boundaries
Superior - tip of scapulae
Lateral - posterior axillary lines
Inferior - iliac crests
includes posterior thoracoabdomen and retroperitoneal space
Organs at risk: the back
Aorta
Vena cava
Duodenum
Pancreas
Kidneys
Ureters
retroperitoneal portions of colon
Shearing injury
A form of crushing injury resulting from use of restraints
Deceleration injuries
Differential movement of fixed and mobile body parts, causing tears at fixed points
- eg liver and spleen laceration
Example injuries from a seat belt across lap
Tear or avulsion of bowel mesentery
Rupture of small bowel or colon
Iliac artery or aortic thrombosis
Lumbar vertebral “chance” fracture
Pancreatic or duodenal injury
Example injuries from a shoulder harness
Upper abdominal viscera rupture
Intimal tear or thrombosis -carotid, subclavian, vertebral arteries
Cervical spine fracture or dislocation
Rib fractures
Pulmonary contusion
Example injuries: air bag
Facial abrasion
Cardiac injury
Spine fractures
Gunshot wound damage - low energy
Tissue damage from lacerating and tearing
Gunshot wounds - high energy
Tissue damage as in low energy
Additional damage based on trajectory, cavitation effect, bullet fragmentation
Explosions - injury pattern
Penetrating fragment wounds
Blunt injuries from being thrown
Overpressure injuries to tympanic membranes, lungs, bowel
Injuries from projectiles
Physical exam findings suggesting pelvic fracture
Evidence of ruptured urethra (scrotal haematome, blood at urethral meatus)
Discrepancy in limb length
Rotational deformity of leg without obvious fracture
Haemorrhage control in pelvic fractures - emergent management
Stabilisation with sheet or binder
Internal rotation of lower extremities
Fluid resus, early transfer
Haemorrhage control in pelvic fractures - definitive management
Angiographic embolisation
Operative haemorrhage control
Pelvic haemorrhage criteria for lapartomy
Intraperirtoneal blood
Signs of urethral injury
Blood at urethral meatus
Scrotal and perineal ecchymosis
Rectal exam purpose in blunt trauma
Spincter tone
Rectal mucosal integrity
Palpable fractures of pelvis
Rectal exam purpose in penetrating trauma
Sphincter tone
Gross blood
Purpose of urinary catheter in trauma
Relieve retention
Identify bleeding
Monitor urinary output
Decompress bladder
Indications for retrograde urethrogram
Patient cannot void
Require pelvic binder
Blood at meatus
Scrotal haematoma
Perineal ecchymosis
X-ray for:
multisystem blunt trauma
pelvic pain/tenderness and haemodynamically abnormal
penetrating abdo trauma
AP CXR
AP pelvic XR
if penetrating trauma haemodynamically unstable, no screening x ray
- if stable with wound above umbilicus, for upright CXR
- if stable with gunshot wound, for supine AXR
Indications for laparotomy in penetrating abdo wounds (7)
- haemodynamically unstable
- peritonitis
- positive FAST/DPL/CT
- evisceration
- free air on imaging
- retained stabbing implement
- blood per gastric, rectal or GU tract
Indications for laparotomy in blunt abdo trauma
- haemodynamically unstable PLUS positive FAST or suspected abdo injury
- positive CT scan and haemodynamic status not improving
- free air on imaging
- evidence of diaphragm rupture
- evidence of intraperitoneal bladder rupture
- peritonitis
Diaphragm injury signs on CXR
- elevation or “blurring” of hemidiaphragm
- hemothorax
- gas obscuring hemidiaphragm
- gastric tube in chest
Treatment of blunt solid organ injuries
Haemodynamically abnormal: urgent laparotomy
Haemodynamically normal: admit for observation and surgical evaluation
When to suspect blunt hollow viscus injuries (4)
- sudden deceleration
- transverse, linear ecchymosis (seatbelt sign)
- lumbar distraction fracture (Chance fracture) on x ray
- abdo pain, tenderness
When to suspect blunt duodenal injuries
- bloody gastric aspirate
- retroperitoneal air on AXR or CT
Direct blow to abdomen, unrestrained driver in frontal impact crash
Blow that would cause pancreatic injury
Direct epigastric blow
Signs of GU injury (5)
- contusions, haematomas and ecchymoses of back, flank, perineum
- gross haematuria
- microscopic haematuria
- multisystem injuries and pelvic fractures
- vaginal bleeding
