Abdominal/pelvic Trauma Flashcards
Evaluation of suspected anorectal injury?
EUA is the gold standard - anoscopy, sigmoidoscopy, vaginoscopy, and cystoscope as indicated.
Consider retrograde urethrogram in the presence of pelvic # as there is a 70% incidence of co-injury.
management of extraperitoneal anorectal injuries?
Primary repair if possible with proximal diversion.
Common location for blunt aortic injury?
Descending aorta at the ligamentum arteriosum.
Findings of BAI on chest x-ray?
Wide mediastinum, deviation of NG to the right, blurred aortic knob, right tracheal deviation, abnormal paraspineal stripe
*funny looking mediastinum.
Priority of injuries with BAI and abdominal hemorrhage?
Laparotomy should take priority before dealing with aorta.
Medical mgmgt of BAI?
beta-blockers
APSA 2019 Admission guidelines for SOI?
ICU- abnormal vitals after initial volume resuscitation.
- Bedrest until vitals normal
- q6h CBC until vitals normal
- NPO until vitals normal and Hgb stable
Ward
- AAT
- CBC on admission and 6 hours later stop when stable
- DAT
APSA SOI 2019 intervention guidelines?
Transfusion - vitals unstable after 20/kg RL
- Hgb <70
- signs of ongoing bleeding
Angio - ongoing bleeding in stable patient
* not for contrast blush
OR - unstable vitals despite transfusion
- consider 1:1:1 transufusion
APSA SOI discharge criteria?
Tolerating DAT
Minimal pain
Normal vitals
APSA 2019 SOI follow up?
- limit activity to grade + 2 weeks
- follow up image symptomatic patients
3 most common mechanisms for duodenal injury?
Handle bar
Lap belt
NAT - if seen in toddler or infant should be highly suspected
AAST grading for duodenal injuries?
1 - hematoma involving one portion or partial thickness lac.
2- hematoma beyond one portion or < 50% disruption
3 - disruption of 50-75% of D2 or 50-100% of D1/3/4
4- disruption of > 75% of D2 or involvement of the ampulla
5 - massive disruption of duodenopancreatic complex or devascularization.
Management of duodenal hematoma?
NPO, NG, TPN
- 90% resolve (usually within 2 weeks)
- Reimage at 2 weeks of still symptomatic at which point may continue observation or operate.
Options for duodenal repair?
- Pyloric exclusion with G-J for grade 3/4 injuries
- Lower grade injuries can be repaired primarily.
- Roux D-J
- De rotation with primary D-J
Should Feeding J-tube be placed after duodenal repair?
yes
What is the lap belt complex of injuries?
Abdominal wall contusion
Chance fracture of the lumbar spine
Isolated small bowel perforation
What is the best diagnostic modality for small bowel injury?
Serial abdominal exams.
Only 1/3 have free air on plain films
AAST splenic injury grading:
1 - hematoma < 10% of surface or lac < 1cm deep
2- hematoma 10-50% or lac 1-3 cm deep
3- hematoma > 50 % or ruptured hematoma, lac > 3cm
4- lac involving segmental hilar vessels with > 25% devascularized spleen.
5- shattered spleen or hilar main vessel injury
AAST liver injury grading:
1- hematoma < 10 % or lac < 1 cm
2- hematoma 10-50% or lac 1-3 cm deep
3- hematoma > 50% or ruptured/expanding, lac > 3 cm deep
4- parenchyma injury involving 25-75 % of a lobe.
5 - parenchyma injury involving > 75% of a lobe, or retrohepatic injury
6- hepatic avulsion
Criteria for CT abdomen in blunt trauma:
Seatbelt sign GCS < 15 Tenderness on exam or complains of pain Decreased breath sounds Vomiting
Failure rate of non-op mgmgt in SOI?
5% - median time to failure 3 hours
76% who fail do so within 12 hours
Chance of rebleed after discharge from hospital for SOI?
1 in 300 at median of 8 days
What is the natural history of spleen and liver pseudo-aneurisms?
Incidence of ~17%, most thrombose without treatment.
Aneurisms from high gradeliver injuries may be higher risk for rupture.
What is the risk of OPSI post splenectomy?
Overall rate is 4.4% under the age of 16
*children under 5 have a rate of 10-15%
How is a bile leak managed post liver injury?
Occurs in grade 3 injuries or above ~5% of the time.
Symptoms include RUQ pain, fever, jaundice
Confirm Dx with HIDA
ERCP to stent duct with perc/lap drainage of collection
Management of hemobilia?
Best managed with hepatic artery emoblization
More common with penetrating injuries.
AAST grading for pancreatic trauma?
1) minor contusion or lac
2) major contusion or lac
3) Distal transection with duct injury
4) Proximal transection or parenchyma injury to ampulla
5) Massive head disruption
Pros and Cons of pancreatectomy vs. non-op mgmt of Grade 3 pancreas injury?
Pros: Lowe pseudocyst formation Shorter time to oral feeds Shorter LOS Visualization of other injuries
Cons: Risk of splenectomy and vascular injury Possible pancreatic insufficiency Post op adhesions Pancreatic fistula
Management options for post-traumatic pseudocyst?
Monitor if asymptomatic
Perc drain - trans gastric
ERCP with stent
Distal pancreatectomy
management of pancreatic fistula?
TPN or post ampullary feeds
Somatostatin
ERCP with stent
