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Abdominal Trauma

Abdominal Trauma

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Abdominal Trauma

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  1. Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007

  2. The Plan • Abdominal Anatomy • Mechanisms of Injury • Common Pathology • Evaluation • Management

  3. Part 1:Abdominal Anatomy

  4. Abdominal Anatomy Basics • ABC’s • Many organs receiving substantial blood flow • Potential spaces that can hide hemorrhage • Hollow organ damage> Peritonitis

  5. Abdominal Anatomy Basics • ABC’s • Many organs receiving substantial blood flow • Potential spaces that can hide hemorrhage • Hollow organ damage> Peritonitis

  6. Abdominal Anatomy Basics • ABC’s • Many organs receiving substantial blood flow • Potential spaces that can hide hemorrhage • Hollow organ damage > Peritonitis

  7. Abdominal Anatomy Basics • ABC’s • Many organs receiving substantial blood flow • Potential spaces that can hide hemorrhage • Hollow organ damage > Peritonitis

  8. Abdominal Anatomy:Four Quadrants

  9. Abdominal Anatomy:Four Quadrants

  10. Abdominal Anatomy

  11. Abdominal Anatomy

  12. Abdominal Anatomy

  13. Abdominal Anatomy

  14. Abdominal Anatomy:Four Quadrants

  15. Alternative Divisions

  16. Intraperitoneal Structures

  17. Retroperitoneal Structures

  18. Upper Abdomen CT

  19. Lower Abdomen CT

  20. Retroperitoneal

  21. Part 2:Mechanisms andPathology

  22. Abdominal Injuries • Blunt vs. Penetrating • Often both occur simultaneously • Blunt is the most common mechanism in US

  23. Blunt Abdominal Trauma • Direct impact or movement of organs • Compressive, stretching or shearing forces • Solid Organs > Blood Loss • Hollow Organs > Blood Loss and Peritoneal Contamination • Retroperitoneal > Often asymptomatic initially

  24. Blunt Abdominal Trauma • Direct impact or movement of organs • Compressive, stretching or shearing forces • Solid Organs > Blood Loss • Hollow Organs > Blood Loss and Peritoneal Contamination • Retroperitoneal > Often asymptomatic initially

  25. Blunt Abdominal Trauma • Direct impact or movement of organs • Compressive, stretching or shearing forces • Solid Organs > Blood Loss • Hollow Organs > Blood Loss and Peritoneal Contamination • Retroperitoneal > Often asymptomatic initially

  26. Blunt Abdominal Trauma • Direct impact or movement of organs • Compressive, stretching or shearing forces • Solid Organs > Blood Loss • Hollow Organs > Blood Loss and Peritoneal Contamination • Retroperitoneal > Often asymptomatic initially

  27. Blunt Abdominal Trauma • Direct impact or movement of organs • Compressive, stretching or shearing forces • Solid Organs > Blood Loss • Hollow Organs > Blood Loss and Peritoneal Contamination • Retroperitoneal > Often asymptomatic initially

  28. Liver Lacerations I. Subcapsular Hematoma <10% Surface Area II. Subcapsular Hematoma 10-50% III. Subcapsular Hematoma >50% IV. Parenchymal Disruption of 25-75% V. Parenchymal Disruption of >75% VI. Liver Avulsion

  29. Splenic Lacerations I. Subcapsular Hematoma <10% Surface Area II. Subcapsular Hematoma 10-50% III. Subcapsular Hematoma >50% IV. Laceration producing devascularization of >25% of the spleen V. Shattered Spleen

  30. Evaluation: Be Suspicious • Mechanism • Vitals • Symptoms • Associated Injuries • Elderly or co-morbidities • Distracting injuries • Decreased MS/intoxication

  31. Physical Exam Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvic are the standard Screening Diagnostic Peritoneal Lavage (DPL) Ultrasound:FAST (serial exams) Techniques for Evaluation

  32. Physical Exam Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvis are the standard Screening Diagnostic Peritoneal Lavage (DPL) Ultrasound:FAST (serial exams) Techniques for Evaluation

  33. Physical Exam Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvis are the standard Screening Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams) Techniques for Evaluation

  34. FAST: RUQ

  35. FAST: RUQ

  36. FAST: RUQ

  37. Organ Specific Dx Only CT Also evaluates retroperitoneum Expensive Radiation Ex Lap Laparotomy gold standard for evaluation Concomitant treatment Retroperitoneum difficult to explore/assess Techniques for Evaluation

  38. Organ Specific Dx Only CT Also evaluates retroperitoneum Expensive Radiation Ex Lap Laparotomy is the gold standard for evaluation Concomitant treatment Retroperitoneum difficult to explore/assess Techniques for Evaluation

  39. Penetrating Trauma Evaluation • Mandatory exploration abandoned • No digital exploration or contrast studies • Inspect wound to determine if there is violation of the fascia • Difficult to assess stab wound trajectory • Determine if gunshot traversed the peritoneal cavity

  40. Management • ABC’s • Fluid resuscitate • To lap or not to lap? • Unstable (with no other reason) • Free air/peritonitis (antibiotics) • Unexplained free fluid • Many splenic/liver lacs managed non-operatively or by VIR

  41. Penetrating Flank and Buttock Injuries • Potential for peritoneal and/or retroperitoneal injury • Similar evaluation and management to abdominal • Buttock injuries may also reach peritoneal and/or retroperitonal structures

  42. Genitourinary Trauma

  43. GU Trauma • 2-5% of adult traumas • Vast majority blunt mechanisms • 80% renal injuries • 10% bladder injuries • Abnormalities (tumor, hydro) increase susceptibility • Rarely require immediate intervention

  44. Evaluation • Rectal - high riding prostate • Perineum - ecchymosis, lacs • Genitals - meatal/vaginal blood • Difficult catheter placement (may need suprapubic) • UA – hematuria (poor correlation to degree of injury)

  45. Evaluation • U/S and Plain films of little use • CT is the superior imaging modality • Careful with contrast (nephropathy) • Angiography remains the gold standard • IVP/Cystoscopy less useful in the ED

  46. GU Injuries: The Kidneys • Kidneys are well protected • Most commonly bruised • Pts with a shattered kidney become rapidly unstable • Renal vascular injuries may result in thrombosed vessels

  47. GU Injuries: The Kidneys Operative management for: • uncontrolled hemorrhage • Penetrating injuries • Multiple lacs • Shattered kidney • Avulsed vessels

  48. GU Injuries: The Bladder • Contusion • Rupture: Intra vs. Extraperitoneal • Extraperitoneal presents with pain, hematuria and inability to void • Urethral injuries: Anterior vs. posterior • No Foley for urethral injuries