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MBBS 3: Surgery > Abdominal Trauma > Flashcards

Abdominal Trauma Flashcards

1
Q

Quadrants of the abdominal region?

A
  1. right/left hypochondriac
  2. epigastric region
  3. right/left lumbar region
  4. umbilical region
  5. right/left iliac region
  6. hypogastric region
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2
Q

Types of Penetrating abdominal injury?

A
  1. Stab wound
  2. Gun shot
    - Projectile injury
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3
Q

Blunt abdominal trauma?

A
  1. Mechanism
    - Crush
    - Deceleration/acceleration
    - Compression
  2. RTA approx. 60 % of all injuries
  3. Solid organs commonly injured
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4
Q

Abdominal evaluation in blunt trauma?

A
  1. Physical Examination
  2. Ultrasound
    - FAST (Focused Abdominal Sonography in Trauma)
  3. Diagnostic Peritoneal Lavage (DPL)
  4. Computed Tomography
    - Only in hemodynamically stable pts
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5
Q

Physical examination in blunt trauma?

A
  1. ATLS-ABCDE
  2. AMPLE history - after stabilization.
    - Collateral: MOI, LOC etc
    - Part of secondary survey
    Caution: TBI, intoxication by alcohol or drugs
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6
Q

FAST ultrasound?

A

focused assessment with sonography in trauma
- designed to detect peritoneal fluid, pericardial fluid, pneumothorax and/or heamothorax in a trauma patient

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7
Q

FAST windows?

A
  1. Morrisons pouch/hepatorenal recess
  2. Splenorenal recess
  3. Pouch of Douglas
  4. Pericardium (xiphoid process)
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8
Q

Diagnostic peritoneal lavage?

A

invasive emergency procedure used to detect hemoperitoneum and help determine the need for laporotomy following abdominal trauma

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9
Q

How is a DPL carried out?

A

a catheter is inserted into the peritoneal cavity followed by aspiration of intraperitoneal contents often after their dilution with crystalloid

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10
Q

Grossly positive aspirate/findings of fluid from DPL in blunt trauma?

A
  1. more than 10ml of blood
  2. aspirate consistent with enteric contents (bile, food particles or vegetable matter)
  3. large fluid that drains into a chest tube or catheter drainage bag
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11
Q

Microscopically positive lavage findings in blunt abdominal trauma?

A
  1. RBC > 100,000/mm3
  2. WBCs>500mm3
  3. alkaline phosphatase>3IU
  4. enteric contents (bile, amylase, bacteria)
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12
Q

Microscopically positive lavage findings in penetrating trauma?

A
  1. RBC > 10,000/mm3
  2. WBCs>50mm3
  3. enteric contents (bile, amylase, bacteria)
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13
Q

Investigations for blunt abdominal trauma in a haemodynamically stable patient?

A
  1. FAST
    - intraperitoneal fluid
  2. CT scan
    - if FAST is positive/intermediate
  3. Clinical observation and serial examinations
    - if FAST is negative
    Consider: Repeat FAST and CT scan
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14
Q

Investigations on blunt abdominal trauma for haemodynamically unstable patients?

A

FAST - intraperitoneal fluid
- if FAST is positive = Laparotomy
- if FAST is negative/intermediate consider:
> other sites of blood loss
> non-haemorrhagic shock
> Repeat fast or DPL

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15
Q

Management of penetrating abdominal trauma is based on?

A
  1. Type: gunshot vs stab
  2. Hemodynamic status
  3. Region of the trunk
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16
Q

Management of penetrating abdominal trauma?

A
  1. Local wound exploration
  2. Non operative management.
  3. Laparotomy
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17
Q

Criteria for performing a laparotomy?

A
  1. Gunshot
  2. Peritonitis
  3. Hemodynamic instability
  4. Evisceration
  5. pneumoperitoneum
18
Q

What are the causes of splenic injuries?

A

Commonly injured in blunt trauma together with liver(Reports vary)
1. MVA
2. domestic violence
3. sports

19
Q

Clinical presentation of splenic injuries?

A
  1. L sided impact
  2. syncope
  3. L-sided abdominal pain & L shoulder pain approx. 15% with splenic rupture.
20
Q

Investigations of splenic injury?

A
  1. Pt with hemorrhagic shock needs DPL/FAST and emergent laparotomy if positive.
  2. Frank peritonitis=laparotomy
21
Q

Classification of splenic trauma?

A

Grade I - V

22
Q

Grade I splenic njury?

A
  • subscapular hematoma <10% of splenic area
  • parenchymal laceration <1cm in depth
  • capsular tear
23
Q

Grade II splenic injury?

A
  • subscapular hematoma 10-50% of splenic area
  • intraparenchymal hematoma <5cm
  • parenchymal laceration 1-3cm in depth
24
Q

Grade III splenic injury?

A
  • subscapular hematoma >50% of splenic area
  • intraparenchymal hematoma >5cm or ruptured subscapular hematoma
  • parenchymal laceration >3cm in depth
25
Q

Grade IV of splenic injury?

A
  • splenic vascular injury or bleeding confined within splenic capsule
  • parenchymal laceration involving segmental or hilar vessels producing >25% devascularisation
26
Q

Grade V splenic injury?

A
  • shattered spleen
  • splenic vascular injury with active bleeding extending beyond the spleen into the peritoneum
27
Q

Management of splenic trauma?

A
  1. 10-15% undergo emergent splenectomy.
    - within the first 6 hours due to ongoing hemorrhage or shock.
  2. Non-op management
    - Goal: salvage the spleen
    - Immune function: Prevents OPSS.
    - Grade 1-3
  3. Operative management
28
Q

Non-operative criteria for splenic injury?

A
  1. Hemodynamic stability
  2. Negative abdominal exam with no other injuries requiring laparotomy
  3. No injuries to preclude abdominal assessment (eg. quadriparesis)
  4. CT scan demonstrating injury grade I, II, or III after initial fluid bolus
29
Q

Operative criteria for splenc injury?

A
  1. Hemodynamic instability after initial fluid bolus
  2. Positive abdominal exam
    i.e. peritonitis
  3. Other abdominal injuries needing operation
  4. Associated injuries precluding abdominal assessment
    e.g. spinal cord injury or severe TBI
  5. CT showing Grade IV-V or hemoperitoneum >500 ml
    NB - Caution: pts>55, on anticoagulant/antiplatelet or cirrhosis.
30
Q

Describe liver injury?

A
  • Commonly injured organ in trauma
  • High frequency in both blunt & penetrating.
  • Other injuries present in 80% wit hepatic injury
    e.g. Splenic, thoracic.
  • Frequently occur at the right lobe.
  • 67% low grade I-III
31
Q

Classification of liver injury?

A

Grade I - VI

32
Q

Grade I liver injury?

A
  • subscapular hematoma <10% of surface area
  • parenchymal laceration <1cm in depth
  • capsular tear
33
Q

Grade II liver injury?

A
  • subscapular hematoma 10-50% of surface area
  • intraparenchymal hematoma <10cm
  • parenchymal laceration 1-3cm in depth, <10cm in length
34
Q

Grade III injury?

A
  • subscapular hematoma >50% of surface area
  • intraparenchymal hematoma >10cm or expanding >3cm in depth
  • expanding or ruptured subscapular hematoma with active bleeding
35
Q

Grade IV of liver injury?

A
  • parenchymal disruprion of 25-75% of a hepatic lobe or involving more than 3 couinaud segments within single lobe
36
Q

Grade V liver injury?

A
  • parenchymal disruption of 25-75% of a hepatic lobe or involving more than 3 Couinaud segments within single lobe
  • juxtahepatic vascular injuries, such as retrohepatic cava or major hepatic veins
37
Q

Grade VI of liver injury?

A

hepatic avulsion

38
Q

Management of liver injury?

A
  1. Hemodynamically unstable pts with +ve FAST/DPL
    - Emergent lap with packing (DCS) or suture to control hemorrhage.
  2. Hemodynamically stable patients- non op
  3. SIRS due to bile leak- surgical exploration.
  4. Penetrating injury confined to the liver can safely be managed non op in hemodynamically stable pt.
39
Q

Describe blunt bowel and mesenteric injury?

A
  • 3rd most common
  • Difficult to diagnose and often missed
  • High index of suspicion
40
Q

What does a CT scan of a blunt bowel and mesenteric injury show?

A
  1. Hard signs:free intraperitoneal air and extravasation of enteric contrast-laparotomy.
  2. Soft signs
    - free fluid without solid organ injury,
    - bowel wall thickening,
    - mesenteric hematoma
    - mesenteric fat stranding

MBBS 3: Surgery (42 decks)

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