Abdominal Trauma

Question 1

Direct blow

• steering wheel, car door
• deforms solid organ > rupture > hemorrhage > leakage of contents > peritonitis

Shearing injuries

• seatbelt
• deceleration injury > differential movement of fixed and nonfixed parts
• splenic or liver lacerations (solid viscus) bucket handle injuries (hollow viscus)

Answer 1

Blunt trauma

Question 2

Low-velocity gunshot wounds (handguns) stab wounds

• lacerating: often small bowel, liver, colon, diaphragm

High velocity gunshot wounds (hunting rifles) explosive devices

• more kinetic injury
• blast pressure = potential for pulmonary or hollow viscous injury
• delayed presentation

Answer 2

Penetrating trauma

Question 3

what should you consider when thinking about trauma

Answer 3

• trauma related hypotension or shock = bleeding until proven otherwise
• trauma hemorrhage sources= blood on the floor and 4 more
  (external bleeding, chest, abdomen/retroperitoneum, pelvis, long bone)

Question 4

Pelvic ring assessment/management

Answer 4

Think fxr: urethral injury, limb length discrepancy, rotational deformity

• known fracture with hypertension= assume unstable pelvic fracture
• do not manipulate if concerned
• +/- pelvic binder

If none of the above are present, manually manipulate pelvis ONCE to assess integrity

• compression/distraction maneuver

may also do urethreal and rectal exam

Question 5

• catheter in the belly
• free aspiration of gross blood, GI contents or bile + HD instability= laparatomy

If no free aspirate

• lavage with 1000ml warmed NS
• mix well
• send effluent to lab

+ DPL

• > 100,000 RBC
• > 500 WBC
• • bacteria on gram stain

Answer 5

DPL= diagnostic peritoneal lavage

Question 6

• rapid, noninvasive, accurate, inexpensive
• can be done at bedside while other resuscitative measures are being performed
• reliably identifies 200-250ml of intraperitoneal fluid
• in experienced hands, sensitivity, specificity, and accuracy is similar to diagnostic peritoneal lavage

Answer 6

FAST exam (Focused, assessment, sonography in trauma)

Question 7

what are the 4 views of the fast exam

Answer 7

• cardiac: parasternal or subixphoid, hepatocardiac interface, pericardial space
• RUQ: hepatorenal interface (morrison’s pouch), diaphragm, inferior pole of kidney
• LUQ: Splenorenal interface, potential space between spleen and diaphragm, inferior pole of kidney, inferior tip of spleen
• Suprapubic: retrovesicular (males), posterior to uterus (pouch of douglas)

Question 8

what are advantages and disadvantages of FAST exam?

Answer 8

advantages

• portable, fast ( < 5min)
• no radiation of contrasat
• less expensive

Disadvantage

• limited for solid parenchymal damage, retroperitoneum or diaphragmatic defects
• limited by obesity, substantial bowel gas, and subcutaneous air
• high false negative rate in detecting hemoperitoneum in the presence of pelvic fracture

Question 9

fast algorithm?

Answer 9

• unstable patient, POS FAST (blood present) = OR
• stable pt, POS FAST = abdominal CT
• Stable pt, low mechanism of injury, NEG fast= observation, serial exams
• CT is gold standard

Question 10

Gold standard

• accurate for solid visceral lesions and intraperitoneal hemorrhage
• guide non-operative management of solid organ damage
• IV, not oral contrast
• disadvantages: somewhat insensitive for injury of the pancreas, diaphragm, small bowel and mesentary
• takes time
• if there is an early or obvious indication for transfer (i.e rural setting or lack of specialists) time consuming test should NOT be performed)

Answer 10

CT scanning

Question 11

indications for emergency laparotomy

Answer 11

• peritonitis
• free air under the diaphragm
• significant bleeding or surgical pathology
• hypotension with + fast scan
• hypotension with penetrating wound
• evisceration
• do NOT keep trauma patients if you lack resources to care for them