Ch. 41 Abdominal Pain Following MVA Flashcards
35 y/o unrestrained male driver brought in by paramedics following MVC. Extensive passenger space intrusion. On arrival, pt is unconscious and unresponsive. BP = 80/40, HR = 110. Facial fractures + blood coming out of mouth. PERRLA. Breathing is shallow and labored. Breath sounds clear bilaterally. Not moving, and withdraws to pain. Abdomen non-distended and non-tender to palpation. No obvious external signs of trauma on abdomen.
Is this pt in shock? What are the different types of shock?
** Hypotension in trauma pts is due to hypovolemic/hemorrhagic shock until proven otherwise. **
What are the clinical manifestations of hypovolemic shock?
- Tachycardia (initial sign)
- Hypotension
- Pale and cool extremities
- Weak peripheral pulses
- Prolonged capillary refill (>2 s)
- Low urine output
- Altered mental status
** Watch out: young pts can be in hypovolemic shock but still maintain normal BP, owing to strong vascular tone which they can maintain until CV collapse is imminent.
What is the significance of blood at the urethral meatus?
Blood at the urethral meatus in the setting of blunt trauma is highly suggestive of urethral injury 2/2 to pelvic fracture
Placing a Foley is C/I due to risk of worsening partial or complete urethral injury
Retrograde urethrogram (RUG) should be performed first to confirm that urethra is intact
What is the significance of gross hematuria?
Srongly suggests injury to kidney or bladder
Renal injury is r/o via CT of abdomen/pelvis with IV contrast… injury to bladder is best determined by either CT cystogram or retrograde cystogram
How much blood loss is necessary to cause hypotension in the supine position?
Hypotension in supine position implies patient has lost 30-40% of his blood volume (Class III) –> 1,500-2,000 ml of blood
What are the 5 main sources (and associated causes) of major blood loss in blunt trauma?
-
Chest
- Massive hemothorax from laceration of lung or bleeding from torn intercostal arteries (both due to rib fractures)
-
Abdomen
- Liver = most commonly injured organ
- Spleen = RARE
-
Pelvis/retroperitoneum
- Torn small arterial branches off the internal iliac artery or pelvic veins
- Renal trauma
-
Long bones
- Femur fractures
-
“Street” or external
- Large scalp lacerations
What do rapid deceleration injuries lead to?
Descending aortic transection (distal to ligamentum arteriosum) –> often fatal
If survived, injury usually contained within mediastinum and less likely to cause massive blood loss
What cavity should not be considered to be the source of hemorrhagic shock and why?
Closed-head injury (cannot lose that much blood into cranium)
Severe closed head –> Cushing reflex (hypertension, bradycardia) via sympathetic response –> peripheral vasoconstriction in order to maintain adequate BP and regulate perfusion to the brain
As a result of vasoconstriction… baroreceptors respond w/ inc. PS stimulation of the heart –> bradycardia
What are the ABCDE of trauma patient mgmt?
Primary survery
-
Airway w C-spine precaution
- Orotracheal intubation using RSI w/ C-spine protection
- RSi designed to prevent aspiration.. involves administering immediate weight-based doses of sedatives (etomidate) and neuromuscular blocking agents in quick succesion
- If emergent setting:
- Cricothyrotomy
- Incision made between thyroid (superior) and cricoid (inferior) cartilages
- Tracheostomy
- More experience necessary…. better long-term mgmt
- Cricothyrotomy
- Orotracheal intubation using RSI w/ C-spine protection
-
Breathing: Once airway secured… important to assess adequacy of oxygenation/ventilation:
- Inspect chest wall for symmetrical mvmt and signs of injury
- Auscultate breath sounds bilaterally
- Palpate for crepitus or chest deformity
- Circulation
- Palpate pulses
- Rough guide: if radial pulse palpable, systolic pressure is at least 80 mmHg… if cartoid or femoral pulses palpable, systolic pressure about 60 mmHg
- Establish peripheral vein access with two large bore (16 gauge or larger) IVs in upper extremities and begin fluid resuscitation if necessary
- Palpate pulses
-
Disability (neurologic eval)
- Assess LOC (GCS - eye, verbal, motor)
- Exposure and environmental control
What is included in the secondary survey of trauma patients?
If pt is conscious and able to speak, conduct quick AMPLE hx
- Allergies
- Meds
- PMH
- Last meal
- Events preceding trauma
Careful and systematic head-to-toe physical exam should be done
Why is nasotracheal intubation not recommended in trauma setting?
Trauma pts may have facial and basilar skull fractures… attempts at NT intubation may lead to inadvertent intracranial passage of nasotracheal tube
How does one confirm proper intubation?
End-tidal CO2 determination (capnograph)
** watch out! end-tidal CO2 determination NOT accurate in pt w/ cardiac arrest
CXR subsequently performed to confirm that endotracheal tube is not advanced too far in tracheobronchial tree (i.e., past the carina)
Ideal Fluid Resuscitation Mgmt in trauma setting
1-2 L Rapid infusion warmed IV crystalloid (squeous solution containing electrolytes)
-
NS (Na 154, Cl) / LR (Na 130, Cl, lactate, K, Ca)
- Sodium maintains tonicity
- Lactate converted to bicarb by liver –> provides buffering
Why are large doses of K+ not given in initial resuscitation?
Due to severe hemorrhage, trauma pts may be in shock –> decreased renal perfusion, decreased GFR –> decreased ability to excrete excess potassium
Trauma pts at risk of developing hyperkalemia due to crush injuries (injury may result in muscle cells releasing potassium)
What is the next step if pt’s vital signs do not approproiately respond to a 2-L fluid challenge?
Presume active bleed
Resuscitate with blood products (type O- PRBCs)
What is the mgmt of intra-abdominal bleeding due to splenic injury?
Most common cause of intra-abdominal BLEEDING following blunt trauma = splenic injury (most commonly injured organ is the liver)
For hemodynamically stable pts with evidence of splenic injury, splenic embolization = preferred mgmt
For hemodynamically unstable pts, surgical exploration + splenectomy = preferred
In pts with splenic injuries that require splenectomy, they must be vaccinated for Strep pneumo and other encapsulated bacteria ideally two weeks after surgery
What is the mgmt of intra-abdominal bleeding due to liver injury?
Most pts with livery injury can be managed conservatively (w/o surgery)
If pt is stable, but demonstrates ongoing bleeding, embolization via IR = accepted therapeutic adjunct
If pt is unstable, surgical exploration = necessary
Bleeding from most liver injuries can be stopped itraoperatively using combo of perihepatic packing (with laparotomy pads), cauterization, and/or suturing
