Blunt Abdominal Trauma Flashcards
DPL remains an excellent tool for ?
for further workup of occult bowel injury or
when FAST is not available or has questionable findings.
Positive DPL
10 mL gross blood
Bacteria
> 100,000 red blood cell/ mm3
Bile
> 500 white blood cell/ mm3
Food particles
> 75 IU/ L amylase
index of suspicion for Bowel injury
predicated on mechanism of injury and physical exam findings
abdominal wall ecchymosis,
tattooing
seat belt sign
CT > extravasation of oral contrast or pneumoperitoneum, bowel wall thickening, stranding of the mesentery, or free fluid in the absence of solid organ injury.
Resuscitation edema may cause a hazy appearance around the head of the pancreas and duodenal c-loop
repeat CT scan with oral contrast and the injection of 300 to 500 mL bolus of air down the nasogastric tube to make pneumoperitoneum obvious.
Blunt Bowel Injury ct findings
Direct findings > extravasation of oral contrast and free air
Indirect findings > mesenteric hematoma or contrast blush, bowel wall edema, unexplained free fluid, “fat streaking,” and bowel loops that do not opacify with intravenous contrast.
a vascular blush in the leaves of the mesentery
indicative of active hemorrhage until proven otherwise
Free fluid in the absence of solid organ injury
further evaluated with DPL or diagnostic peritoneal aspiration (DPA)
if the abdominal exam is unreliable
nondestructive wounds Small bowel
Grade 1 and 2 , managed with debridement and primary-suture enterorrhaphy
Destructive wounds
Grade 3 to 4 , resection of an entire segment of the bowel
relative contraindication to definitive repair
An interval from injury to repair greater than 12 hours if there is widespread (greater than one quadrant) fecal contamination.
AIDS and cirrhosis
these patients may be better off with the establishment of an ostomy.
How can larger wounds contributing to ongoing soiling be temporarily controlled?
controlled with a “whip stitch” (quick running suture) or Babcock clamps
What should be done after identifying mesenteric injuries?
Active bleeding should be controlled appropriately
In mesenteric injuries encroaching on the root of the mesentery, what specific area should attention be directed to?
The location of the superior mesenteric artery
What should be done with mesenteric hematomas?
Mesenteric hematomas should be explored with ligation of injured vessels, and mesenteric defects should be closed by careful reapproximation of the peritoneal edges
How should mesenteric defects be closed to avoid compromising vasculature?
By carefully reapproximating the peritoneal edges without compromising associated vasculature
What should be noted in relation to any mesenteric injury?
Bowel viability.
How can clusters of grade I and II injuries be managed?
They may be resected or individually repaired
How should small, superficial grade I bowel injuries be managed?
They can be left alone without intervention
How should deeper, longer grade I bowel injuries be closed?
They can be closed with a simple running suture or interrupted Lembert sutures
What is the appropriate management for grade II bowel wounds?
They should be debrided back to healthy, viable bowel and closed transversely to prevent narrowing of the lumen.
What type of closure is generally sufficient for repair of small bowel wounds?
A single-layer running or interrupted closure is generally sufficient.
When might a two-layer closure be preferential for bowel repair?
When there is significant bowel wall edema, peritonitis, or soiling
How is a two-layer closure typically performed?
A running inner layer and an interrupted Lembert outer layer are used
How should grade I colon wounds be managed?
Grade I colon wounds may be managed with single-layer closure
What is the recommended closure method for grade II colon wounds?
Grade II colon wounds should be closed in two layers for added protection
What is Kehr’s sign?
Referred pain to the left shoulder on deep inspiration in the presence of a splenic hematoma
What factors increase the risk of failure in nonoperative management of splenic injuries?
Higher AAST splenic injury grade, age greater than 55 years, moderate to large hemoperitoneum, subcapsular hematoma, and portal hypertension.
Why do patients with a splenic subcapsular hematoma or a history of portal hypertension require special consideration in splenic injury management?
These patients are at increased risk for delayed rupture 6 to 8 days following injury, often after hospital discharge
Why is splenic embolization not very effective for treating a splenic subcapsular hematoma?
It usually necessitates coiling of the main splenic artery, which can lead to significant pain and abscess formation
What must be carefully weighed when considering laparotomy in patients with Child-Pugh B or C cirrhosis?
The general risks of laparotomy must be weighed against the risk of worsening coagulopathy in these patients.
When might splenic artery embolization be dictated in patients with portal hypertension or cirrhosis?
It may be required when balancing the risks of laparotomy with the potential for worsening coagulopathy
How quickly do lower-grade (I, II) splenic injuries tend to heal?
Lower-grade injuries tend to heal more quickly, and almost all are healed by 5 to 6 weeks.
What percentage of blunt splenic injuries may not show complete healing?
Approximately 20% of blunt splenic injuries may not show complete healing