Abdominal trauma

Question 1

Discuss injuries associated with the three point restraint

Answer 1

Shoulder belt
- right sided and left sided rib fractures depending on side of the car

Lap belt

• compression of the bowl between the belt and the vertebral colum resulting in a contusions or perforation of the intestines or a tear of the mesentery.
• Approx 25% have hemoperitoneum from mesenteric tears

Rupture of the diaphragm can also occur in cases of high speed frontal impact.

Question 2

Discuss the utility of lipase or amylase in abdominal trauma

Answer 2

Limited utility as normal values do not exclude pancreatic injury

Question 3

Discuss CT imaging in abdominal trauma

Answer 3

• Most accurate for solid viscera
• Defines the presence, source and approximate quantity of intraperitoneal haemorrhage
• it can demonstrate active bleeding from the liver or spleen and can be used to determine whether observation, therapeutic angiographic emobilization or open operative intervention is indicated.
• Evaluates the retroperitoneal space not seen on FAST + evaluates t and l spice.

Decreases cost and morbidity assoicated with laparotomies for slef limiting injuries to the liver.

Question 4

List intra-abdominal injuries that CT is relatively poorly sensitive

Answer 4

• Bowel
• Pancreas
• diaphragm
• mesentery

Question 5

Discuss disadvantages of CT scanning

Answer 5

Radiation
Contrast - allergy, + nephropathy
Most places will have to leave resus for IX

Question 6

Discuss general approach to penetrating injury in the anterior abdomen

Answer 6

1) is an emergent laparotomy indicated
2) has the peritoneum been violated
3) Does an intraperitoneal injury exist and is fo is laparotomy required.

Question 7

List indications for an emergent laparotomy and situations in which it is considered

Answer 7

Indicated

1) HD instability with likley abdominal cause +ve fast
2) Peritoneal signs
- unreliable especially immediately post injury
3) Evisceration
- patients with viscus evisceration sustain up to an 80% incidence of major intraperitoneal injury
4) left sided diaphragm injury
- stomach or bowel in the left chest

Considered

1) GI haemorrahge
2) implement in-situ
3) intraperitoneal air

Question 8

Discuss assessing if peritoneum has been violated

Answer 8

1) Evisceration of bowel or omentum is clear evidence of peritoneal entry
2) Intraperitoneal air
3) Local wound exploration
4) FAST - demonstrating hemoperitoneum
5) laparoscopy

Question 9

Discuss operative vs non-operative management of intraperitoneal injury

Answer 9

Many patients even those with moderate to high grade liver or spleen injury can be managed conservatively

Several pitfulls are worthy of note

1) hollow viscera injury when present requries operative management
2) Altered sensorium patient are most vulnerable to having delayed diagnosis of perforated intestinal injury becuase of delayed or impaired development of finding.
3) expectant management may ear to increased use of products
4) If fails the lag time from injury to operative may increase morbidity and morality

Question 10

Discuss the use of therapeutic angioembolisation

Answer 10

Time consuming procedure is usually reserved for the usntable blunt trauma and pelvic fracture in whom it can be used to emoblise bleeding vessles.

Nil significant difference in regards to mortality or HD status between Lap and angio

Nonoperative management has become the mainstay of splenic injury but failure rates increase as the grade of injury increases - the use of angioembolisation significantly increases the rates of success - Added benefit over splenectomy to preserve spleinc immunity

Question 11

List ct finding in bowel

Answer 11

Definitive signs

1) visible bowel discontinuity
2) Perforation
- pneumoperitoneum in blunt - not specific in penetrating as can entrain with injury
- extra-luminal contrast leak

Suggestive

1) mural haematoma - discontinuity in the bowel wall with mural thickening
2) moderate to large volume of free fluid without solid organ injury
3) intermesenteric fluid forming triangles
4) abnormal bowel wall enhancement
5) positive seat belt sign

Question 12

Discuss CT finding in mesenteric injury

Answer 12

Definitive

1) active extravasation of contrast indicitiave of active bleeding
2) intermesenteric free fluid often forming triangles
3) bleeding and termination of mesenteric vessels
4) abrupt termination of the mesenteric vessels
5) accumulation of contrast on multiphase imaging

Suggestive

• mesenteric infiltration: haziness and fat stranding
• mesenteric haemoatoma
• bowel wall thickening