Chapter 5- Abdominal/ Pelvic Trauma Flashcards
area that is inferior to trans-nipple line, infrascpaular and includes diaphragm, liver, spleen, stomach
Thoraco-abdomen
What level does the diaphragm rise to during expiration
4th ICS
areas between anterior and posterior axillary lines from 6th ICS to iliac crest.
flank
area posterior to posterior axillary line and goes from tip of scapula to iliac crest
back
what organs are retroperitoneal
abdominal aorta, inferior vena cava, duodenum, pancreas, kidneys, uterus, parts of the colon
why is it difficult to diagnose injuries to the retroperitoneum
difficult to see on FAST, not sampled by DPL
what organs are in the pelvic cavity
rectum, bladder, iliac vessels, female reproductive
most frequently injured organ from blunt abdominal trauma
spleen
other organs injured by blunt abdominal trauma
liver, small bowel (also consider retroperitoneal hematoma)
most common organ injured by penetrating abdominal trauma
liver
other organs injured by penetrating abdominal trauma
small bowel, diaphragm, colon
at what length does the liklihood of major visceral injuries decrease with GSWs
beyond 10 feet/ 3 meters
why should hypothermia be prevented
contributes to coagulopathy and ongoing bleeding
loss of bowel sounds may indicate what
ileus from free intraperitoneal blood or GI contents
If a patient has pain on percuss should further palpation be done for rebound tenderness?
No- may cause unecessary further pain
a high riding prostate gland is a sign of what
significant pelvic fracture
PE signs of a pelvic fracture
evidence or rupture urethra, limb length discrepancy, rotational deformity of leg w/o obvious fracture
what PE signs are evidence of a rupture urethra
high riding prostate, scrotal hematoma, blood at uretral meatus
Should you perform manual manipulation of the pelvis if there is an obvious fracture
no, as it can cause further hemorrhage
who are foley catheters to not be placed in
patients with a perineal hematoma or high riding prostate
what can cause lacs of the vagina
bony fragments from pelvic fractures or penetrating wounds
why are gastric tubes inserted
relieve acute gastric dilation, decompress teh stomach before a DPL, remove gastric contents
what does presence of blood in gastric conetents suggest
injury to esophagus or upper GI tract (if nasopharyngeal/ oropharyngeal sources excluded)
When should a gastric tube be inserted via the mouth
if severe facial fracture/ basilar skull fracture , mid face injury
goals on inserting a urinary cath
relieve retnetion, decompress bladder before performing DPL, monitor UOP as sign of tissue perfusion
gross hematuria is a sign of what
trauma to GU tract and nonrenal intrabdominal organs
does absence of heamturia r/o an injury to the GU tract?
No
reasons to perform a retrograde urethrogram to confirm intact urethra before inserting foley
inability to void, unstable pelvic fracture, blood at meatus, scrotal hematoma, perineal eccymoses, high riding prostate
Contraindication to performed FAST/ DPL
existing indication for lapartotomy
What does FAST stand for?
Focused Assessment Sonography in Trauma
Where are FAST scans done?
pericardial sac
hepatorenal fossa & morrison’s pouch
splenorenal fossa
pelvis or pouch of Douglas (suprapubic)
When should FAST exams be performed
initially then 30 minutes later to monitor progressive hemoperitoneum
What transducer is used for FAST
low frequency 3.5 MHz transducer
What color is fluid in the heart on FAST
black
Where do you obtain the RUQ view for FAST
midaxillary line at 10-11th rib space. visualize diaphragm, liver, kidney, morrison’s pouch
what is morrison’s pocuh?
hepatorenal fossa
Where is the LUQ view obtained for FAST
midaxillary at 8th or 9th ICS. visualized diaphragm, spleen, kidney
DPL indication
hemodynamically normal patients w/ blunt injury when US or CT is not available
hemodynamically unstable pts w/ multiple blunt injuries / penetrating useful too
Relative C/I to DPL
previous abdominal operations, morbid obesity
advanced cirrhosis, preexisting coagulopathy
DPL approach preferred in pelvic fracture
supraumbilical approach
typical approach for DPL
infraumbilical technique
Findings from DPL that indicate need for laparotomy
free aspiration of blood, GI contents, vegetable fibers, bile
If greater than 10 mL of blood or GI contents aren’t aspirated from DPL initially what is done
lavage is performed with 1000 mL of warmed isotonic crystalloid solution (10 mL/kg in kid) then make sure fluid mixes with peritoneal (log rolling, head down/ up positions)
CT is only indicated in what type patients
hemodynamically normal patients who there is no apparent indication for an emergency laparotomy
when should urethrography be performed
before inserting an indwelling urinary catheter when urethral injury is suspected (insert undiluted contrast through 8 French urinary cath secured in meatal fossa) X-ray taken with A/P projection w/ penis stretched towards shoulder.
What is a intraperitoneal or extraperinteal bladder rupture best diagnosed by
cystogram or CT cystography
what are suspected urinary system injuries best evaluated by
contrast-enhanced CT scan (if not available then Intravenosu pyelogram)
how are most GSWs to the abdomen managed
exploratory laparotomy
indications for laparotomy in patients with penetrating abdominal wounds
hemodynamically abnormal
GSW w/ transperitoneal trajectory
signs of peritoneal irritation
signs of fascia penetration
what is double contrast
IV and oral
what is triple contrast
IV, oral, and rectal
way to evaluate flank and back injuries in relatively asymptomatic patients
serial PEs
double or triple contrast CTs
indications for laparotomy
blunt abdominal trauma w/ HPOTN, +FAST, DPL
HPOTN + penetrating abd wound
GSW into peritoneal/ vascular retropertoneum
evisceration
bleeding from stomach, rectrum, GU
peritonitits
free air, retroperitoneal air,hemidiaphragm rupture
which hemidiphragm is most commonly injured
left (posterolateral)
signs of tear in diaphragm
elevation or “blurring” of hemidiaphragm, hemothorax, abnormal gas shadow
who is duodenal rupture common in
unrestrained drivers in frontal-impact MVA
direct blow to abomdne (bike handlebars)
signs of duodenal injury
bloody gastric aspirate, retroperitoneal air on flat plate x-ray or abdominal CT
studies indicated for patients at high risk for duodenal injury
upper GI x-ray series or double contrast CT
does a normal serum amylase level exclude pancreatic trauma
No
most common cause of pancreatic injuries
direct epigastric blow that compresses organ against vertebral column
Does double contrast CT identify significant pancreatic trauma up to 8 hours post injury
it may not, should repeat CT if suspected
what typically causes hollow viscus injuries
blunt injury to the intestines from sudden deceleration w/ subsequent tearing near a fixed point of attachment
msot common force that causes a pelvic fracture
lateral compression (closed) . lead to inernal rotation of the involved hemipelvis
is life threatening hemorrhage common in lateral compression (closed) pelvic injury
no since the pelvic colume is actually compressed
When does an AP compression pelvic injury occur
auto-ped, motocycle, direct crush injury, fall from height >12 feet. opening of pelvic can lead to significant hemorrhage from posterior pelvic venous complex
IF there is gros sintraperitoneal blood with a pelvic fracture what is indicated?
laparotomy
what is a positive DPL
Gross blood aspirated, >100,000 RBCs, >500 WBCs, positive gram stain for food fibers/ bacteria
does a negative DPL exclude retroperitoneal injuries such as pancreatic/ duodenal
No (outside peritoneum)
What should be done for DPL
decompress stomach and urinary bladder
complications from DPL
hemorrhage, peritonitis, laceration of bladder, injury to abdominal/ retroperitoneal structure, wound infection at site
