Abdominal injury

Question 1

What would you do before assessing a patient with abdominal injury after high-speed mechanism of injury?

Answer 1

• put out 2222 trauma call
• move pt to resus

Question 2

A - airway/C-spine

Answer 2

• triple immobilise cervical spine
• ensure airway patency

Question 3

B - breathing

Answer 3

• Administer high flow O2 (15 L via non-rebreather mask)
• Gain observations: oxygen saturation, respiratory rate.
• Inspect/ palpate thorax for equal chest movements and signs of trauma
• Auscultate and percuss chest
• CXR
• ABG

Question 4

C - circulation and control of haemorrhage

Answer 4

• Assess haemodynamic stability with blood pressure, heart rate, ECG and peripheral circulation
• IV access with 2 wide bore cannulae
• Send off bloods including FBC, U&E, LFT, clotting, G&S and x match
• Commence warmed IV fluids or O- blood, as indicated
• Assess for major bleeding sources – considering bleeding into thorax, abdomen, pelvis, long bones and peripherally (“blood on the floor and 4 more”). Ordering x-rays and FAST scan as required. Considering immediate management such as pelvic binders until pelvic fractures have been excluded in the context of acute haematuria.

Question 5

What intervention can be done immediately with acute haematuria?

Answer 5

Pelvic binder until pelvic fracture is excluded

Question 6

D - disability

Answer 6

• Assess conscious level (GCS or AVPU)
• Assess for lateralizing sign
• Temperature
• BM/ blood glucose

Question 7

E - exposure

Answer 7

Completely expose patient to assess for any missed injuries whilst avoiding hypothermia.

Question 8

What are some differential diagnoses for LUQ pain in the context of abdominal injury?

Answer 8

• Perforated viscus (GI tract perf)
• Splenic injury/ rupture
• Left kidney injury
• Pancreatic injury (tail or body)
• Diaphragmatic injury

Question 9

What are some differential diagnoses for frank haematuria in the context of abdominal injury?

Answer 9

• Renal injury – associated with lower rib and vertebral fractures
• Ureteral injury – associated with lower rib and lumbar vertebral fractures
• Bladder injury – may be associated with pelvic fracture
• Urethral injury –
  – posterior (above the urogenital diaphragm) – associated with pelvic fracture
  – anterior (below the urogenital diaphragm) – associated with straddling injuries.

Question 10

What investigations would you order?

Answer 10

• Haematological: FBC, U&E, LFT, blood gas, G&S/ X-match
• Radiological: bedside US scan or CT abdo/pelvis or ideally full trauma series CT scan (thorax, abdomen, head and neck)
• CT urogram may also be indicated in haematuria

Question 11

CT shows [thing you don’t really know]. How would you proceed?

Answer 11

• reassess - ABCDE
• Senior assistance - contact X registrar and discuss findings using SBAR approach
• follow senior advice since I don’t know

Question 12

What is the AAST (American Association of the Surgery in Trauma) renal injury scale?

don’t acc NEED to know this

Answer 12

• Grade I: contusion or non-enlarging subcapsular perirenal haematoma, and no laceration
• Grade II: superficial laceration <1 cm depth and does not involve the collecting system (no evidence of urine extravasation), non-expanding perirenal haematoma confined to retroperitoneum
• Grade III: laceration >1 cm without extension into the renal pelvis or collecting system (no evidence of urine extravasation)
• Grade IV
  – laceration extends to renal pelvis or urinary extravasation
  – vascular: injury to main renal artery or vein with contained haemorrhage
  – segmental infarctions without associated lacerations
  – expanding subcapsular haematomas compressing the kidney
• Grade V - NEEDS SURGERY
  – shattered kidney
  – avulsion of renal hilum: devascularisation of a kidney due to hilar injury
  – ureteropelvic avulsions
  – complete laceration or thrombus of the main renal artery or vein

Question 13

What does the FAST exam include?

Answer 13

• pericardial sac
• hepatorenal fossa
• splenorenal fossa
• pelvis or pouch of Douglas

Question 14

Indications for laparotomy

Answer 14

• blunt abdominal trauma with hypotension, positive FAST or clinical evidence of intraperitoneal bleed, or without other source of bleeding
• hypotension with abdominal wound that penetrates into fascia
• gunshot wound that traverses peritoneal cavity
• evisceration
• bleeding from stomach, rectum, GU tract following penetrating trauma
• peritonitis
• free air
• contrast CT showing ruptured GIT, intraperitoneal bladder injury, severe visceral parenchymal injury after blunt or penetrating trauma
• trauma with aspiration of GI content or blood etc