Abdominal and Pelvic trauma Flashcards
Clinical regions of the abdomen
Anterior abdomen
Thoracoabdomen
Flank
Back
Pelvic cavity
Boundaries of anterior abdomen
Superior - costal margins
Inferior - inguinal ligaments and pubic symphysis
Lateral - anterior axillary lines
Organs at risk in the anterior abdomen
Most solid and hollow viscera
Boundaries of the thoracoabdomen
Superior - nipple line anteriorly, infra-scapular line posteriorly
Inferior - costal margins
No lateral boundary as runs around entire circumference of torso
Organs at risk in the thoracoabdomen
Diaphragm
Liver
Spleen
Stomach
Boundaries of the flank
Superior - 6th intercostal space
Anterior - anterior axillary line
Posterior - posterior axillary line
Inferior - iliac crest
Organs at risk in the flank
Most hollow viscera
Diaphragm
Liver / spleen
Stomach
Boundaries of the back
Superior - tip of the scapulae
Lateral - posterior axillary lines
Inferior - iliac crests
Includes the posterior thoracoabdomen and retroperitoneal space
Organs at risk in the back
Aorta + Vena cava
Duodenum
Pancreas
Kidneys + Ureters
Retroperitoneal parts of ascending / descending colon
Boundaries of the pelvic cavity
Pelvic bones
Contains lower part of the retroperitoneal and intraperitoneal spaces
Organs at risk in the pelvic cavity
Rectum
Bladder
Iliac vessels
Internal reproductive organs (females)
Blood loss from bony pelvis
Forms of blunt trauma
Direct blow
Shearing forces
Deceleration
Direct blow consequences
Can cause:
- Compression and crushing injuries
- Rupture
- Secondary haemorrhage
- Contamination by visceral contents
Shearing forces mechanism
Can result from use of restraints and cause crushing injury
Deceleration forces mechanism
Differential movement of fixed and mobile parts of the body
Can cause tears at fixed points
(eg. liver and spleen which are mobile organs tethered at fixed points by supporting ligaments)
Injuries associated with lap seat belt restraint
Tear / avulsion of bowel mesentery
Rupture of bowel
Iliac artery / aortic thrombosis
Lumbar vertebra “Chance” fracture
Pancreatic / duodenal injury
Lumbar vertebral chance fracture
Caused by flexion-distraction injury
Unstable
Horizontal fracture through spinous process, pedicles and vertebral body
Injuries associated with shoulder harness restraints
Upper abdo viscera rupture
Tear / thrombosis of carotid, subclavian or vertebral arteries
C spine fracture / dislocation
Rib fracture
Pulmonary contusion
Injuries associated with air bag use
Face and eye abrasions
Cardiac injuries
Spine fractures
Mechanism of injury with low energy penetrating trauma (inc low energy gunshot wounds)
Tissue damage from lacerating and tearing
Mechanism of injury with high energy penetrating trauma (inc high energy gunshot wounds)
Additional tissue damage due to trajectory, cavitation effect and bullet fragmentation
Mechanisms of injury associated with explosions
Penetrating fragment wounds
Blunt injuries from being thrown
Physical examination findings which suggest pelvic fractures
Ruptured urethra (scrotal haematoma or blood at urethral meatus
Discrepancy of limb length
Rotational leg deformity with no clear fracture
How frequently should pelvis be assessed for mechanical stability
Not at all as may disrupt existing blood clot
Assume instability of pelvic ring where pelvic fracture suspected
Use pelvic binder
Useful information in patient Hx for motor vehicle crash
Speed
Collision type
Intrusion into passenger compartment
Ejection
Restraint type
Air bag deployment
Patient position
Status of other passengers
Useful information in patient Hx for falls
Height of fall
Useful information in patient Hx for penetrating trauma
Time of injury
Type of weapon
Distance from assailant
Number of stab / gunshot wounds
Amount of external blood at scene
Useful information in patient Hx for explosion
Distance from explosion
Enclosed or open space
Secondary impact (eg thrown / fall)
Secondary projectiles
Important evaluation in pregnancy with abdo trauma
Estimate foetal age
Benefit from using a pelvic binder
Reduces pelvic radius and therefore reduces potential space available for blood loss
Methods of haemorrhage control from pelvic fracture in ED
Stabilisation with:
- Pelvic binder (at level of greater trochanters)
- Sheet
- Internal rotation of lower limbs
Methods of definitive haemorrhage control in pelvic fractures
Surgery
Angiographic embolization
Contraindication to bladder catheterisation
Perineal haematoma or blood at urethral meatus before definitive assessment for urethral injury
When to perform rectal, vagina or gluteal examination
Bony fragments from pelvic fracture or penetrating injury suspected
Goal of gastric tube placement in trauma patients
Relieve gastric dilatation and decompress stomach
Blood in gastric contents of gastric tube
Suggests oesophageal or upper GI injury
Contraindication to NG tube
Facial fractures
Basal skull fractures
Options when NG tube contraindication
Insert gastric tube through mouth
(Orogastric tube rather than Nasogastric tube)
Goals of urinary catheterisation
Identify bleeding
Monitor UO
Decompress bladder (wait until after FAST scan if can)
Which patients require retrograde urethrogram
Cannot void bladder
Require pelvic binder
Blood at urethral meatus
Scrotal haematoma
Perineal ecchymosis
Most common cause of free fluid in abdomen with abdominal organs intact on CT
Mesenteric tears
Bowel rupture
Seat-belt sign
Have high suspicion of bowel injury
XR to perform in Haemodynamically Abnormal patient with penetrating abdominal trauma
No screening X rays
XR to perform in Haemodynamically Normal patient with penetrating abdominal trauma - wound above umbilicus or suspected thoracoabdominal injury
Erect CXR
XR to perform in Haemodynamically Normal patient with penetrating abdominal trauma - with gunshot wound(s)
Supine abdo XR
Advantages of FAST scan
Early operative determination
Non-invasive
Repeatable
Rapid
Disadvantages of FAST scan
Operator dependant
Bowel gas / body habitus can distort images
Can miss diaphragm or pancreas injury
Does not fully assess retroperitoneal structures
Goal of diagnostic peritoneal lavage (DPL)
Rapidly identify intraperitoneal bleeding and need for operation
When is DPL most useful
Haemodynamically Abnormal patients with:
- Blunt abdo trauma
- Penetrating abdo trauma without indication for immediate laparotomy
Can be performed in resuscitation area
Disadvantages with DPL
Invasive
Requires surgical expertise
Relative contraindications to DPL
Previous abdo surgery
Morbid obesity
Advanced cirrhosis
Pre-existing coagulopathy
Indications for immediate emergency laparotomy in patients with penetrating abdominal wounds
Any haemodynamically abnormal patient
Gunshot wound with transperitoneal trajectory
Peritonitis
Signs of peritoneal penetration (eg. evisceration)
Free / extra-luminal air on imaging
Retained stabbing implement
Positive FAST / DPL / CT
Blood per gastric, rectal or genitourinary tract
Indications for immediate emergency laparotomy in patients with blunt abdominal trauma
Haemodynamically abnormal with positive FAST / DPL or suspected abdo injury
Positive CT scan and haemodynamic status not improving
Extra-luminal air on imaging
Evidence of diaphragm rupture
Evidence of intraperitoneal bladder rupture
Peritonitis
When to suspect blunt hollow viscus injuries
Sudden deceleration mechanism
Seat-belt sign
Lumbar chance fracture
Abdo pain / tenderness
When to suspect blunt duodenal injuries
Unrestrained driver in front impact crash
Direct abdominal blow
Blood in gastric aspirate
Retroperitoneal air on imaging
Mechanism for blunt pancreatic injuries
Compression of pancreas against vertebral column
From direct epigastric blow
