Abdominal trauma

Abdominal trauma PRESENTED BY: Dr LouzaAlnqodi, R3

outlines • Background • Clinical assessment of pt with blunt , penetrating abdominal injuries • Diagnostic tools • Clinical approach • Conclusion.

R1 • Which of the following does not cause a falsely +ve DPL? *Abdominal wall hematoma *inadequate homeostasis *pelvic # *retroperitoneal injury

R1 • Which of the following does not cause a falsely +ve DPL? *Abdominal wall hematoma *inadequate haemostasis *pelvic # retroperitoneal injury

R2 • Criteria for a +ve DPL include all of the following except: *initial aspiration of at least 50ml gross blood *>100,000 RBC in blunt trauma *>5000 RBC in gunshot or penetrating low chest wound. *presence of bile, bacteria or meat/vegetable fibers

R2 • Criteria for a +ve DPL include all of the following except: initial aspiration of at least 50ml gross blood *>100,000 RBC in blunt trauma *>5000 RBC in gunshot or penetrating low chest wound. *presence of bile, bacteria or meat/vegetable fibers

R3 During the evaluation of a trauma patient, an upright CXR showed gastric bubble shifted to the rt . No free air is present. What is the main concern? *bowel perforation *gastric injury *retroperitoneal hematoma *splenic injury

R4 • All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one? • *bowel protrusion or evisceration • *evidence of diaphragmatic injury • *indeterminate local wound exploration • Peritoneal irritation on physical examination • Significant GI bleeding

R5 • A 25 yr old male presents with a stab wound to the upper abdomen. Vital signs are stable. The abdomen is not distended, soft, non-tender. Bowel sounds are present. Upright CXR does not demonstrate a Penumothorax or free air under diaphragm. What should the next step be? *evaluation of the peritoneal entry by local wound exploration *performing DPL *Proceeding directly to Laprotomy *suturing of the wound and discharging the pt with clear instruction.

anatomy • Anterior abdomen • flank • Back • intraperitoneal contents • Retroperitoneal space contents • Pelvic cavity contents

Anterior abdomen: trans-nipple line, , anterior axillary lines, inguinal ligaments and symphysis pubis. • flank: anterior and posterior axillary line ;sixth intercostal to iliac crest • Back: posterior axillary line; tip of scapula to iliac crest

Peritoneal cavity: upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-small bowel, sigmoid colon • Retroperitoneal space: aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending and descending colons • Pelvic cavity: rectum, bladder, iliac vessels and internal genitalia

mechanism • Blunt trauma: MVC Seatbelt injury fall from ht crash injury sport injury • Penetrating injuries.

Blunt abdominal injuries carry a greater risk of morbidity and mortality than peneterating abdominal injuries.

associated with severe trauma to multiple intraperitoneal organs and extra-abdominal systems • altered mental status, intoxication • Peritoneal signs are often subtle and may be obscured by other painful injuries • Up to 20% of patients with hemoperitoneum have benign abdominal exams on initial presentation.

Blunt injury Spleen (40-55%) Liver (35-45%) Small bowel (5-10%) Retroperitoneal hematoma: 15%

Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE? • CT scan may confirm injury, but should not delay laparotomy in unstable patients. • Twenty percent of patients with left lower rib fractures have associated splenic injury. • Focused Assessment with Sonography for Trauma is useful if performed by experienced users. • Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.

Seatbelt injuries Unrestrained front and rear seat passengers are at unequivocally greater risk of intra-abdominal injury than their restrained counterparts. The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries. However, abdominal injuries are still ascribed to shoulder-lap and lap-belt systems.

pathogensis • compression of bowel between the belt and the vertebral column. • an acute short closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures.

Clinically, two symptom patterns emerge. • ~1/4 of pt develop evidence of a hemoperitoneum secondary to mesenteric lacerations. • In the remainder, the intestinal injury most commonly involves the jejunum contusion or perforation. • Rare cases of acute abdominal aortic dissection with incomplete or complete occlusion have also been described, and injuries to the lumbar spine are not uncommon.

Penetrating abdominal trauma

Mechanism • Stab wound • gunshot

Knives are not the sole implement used in stabbings. • Ice picks, pens, coat hangers, screwdrivers, and broken bottles. • most commonly in the upper quadrants, the left more commonly than the right.

Stab wound • multiple in 20% of cases • involve the chest in up to 10% of cases. • Most stab wounds do not cause an intraperitoneal injury • the incidence varies with the direction of entry into the peritoneal cavity • The liver, followed by the small bowel, is the organ most often damaged by stab wounds.

Gunshot Wounds • handguns, rifles, and shotgun • the degree of injury depends . • amount of kinetic energy imparted by the bullet to the victim • mass of the bullet and the square of its velocity • Distance .

Missile velocities : low (slower than 1100ft/sec) medium (1100-2000ft/sec) high (faster than 2000-2500ft/sec)

type I wounds: long range (>7 yards) , a penetration of subcutaneous tissue and deep fascia only. • Type II wounds: distance of 3 to 7 yards and may create a large number of perforated structures. • Type III wounds occur at point-blank range (<3 yards) and involve a massive destruction of tissue

multiple organ injuries are sustained, notably perforations to bowel . • greatest for small bowel, followed by the colon and then the liver.

Missiles effects • Extensive tissue damage • external contaminants tend to be dragged into the wound. • the closure of the tract immediately after the bullet's passage may lead to an underestimation of tissue damage. • high-velocity bullets can fragment internally

Small bowel injury is the most common injury resulting from ___ abdominal trauma. • penetrating • blunt

CLINICAL ASSESSMENT OF PT WITH ABDOMINAL TRAUMA .

history • Primary goal is to identify that an injury exists, not necessarily making an accurate diagnosis. • The patient's history may be unobtainable, elusive, or temporarily abandoned while resuscitative measures are carried out. • History from prehospital care team or transferring hospital : the vital signs, physical assessment, prehospital course, and response to therapy should be obtained • Mechanism of injury is an important factor in developing a high index of suspicion; thus a detailed history is helpful if available.

Details about accident • Damage to car • Velocity • Steering wheel damage • Type of seatbelts used • Air bags deployed • All patients involved in deceleration injuries and bicycle injuries should be suspected of having intraabdominal injury

In penetrating trauma: • # of shots or stabs • Type of weapon • Distance b/w firearm and victim

examination • Overall, the accuracy of the physical examination in patients with blunt abdominal trauma is 55% to 65%. • Although the presence of physical findings makes intraperitoneal injury more likely, their absence does not preclude serious pathology, and none is exclusively diagnostic of a specific injury.

Hypotension in the acute stage results from hemorrhage that is most often from a solid visceral or vascular injury. • hypotension with significant multiple blunt trauma and is unexplained, one should assume the presence of intraperitoneal hemorrhage until it is excluded.

In conscious, alert pt, look for: • Abdo tenderness,90% • Peritoneal irritation • Penetrating: wounds (log roll pt) • Ecchymosis, Cullen and Gray-Turner signs

Rectal exam is important; assess for blood and palpable bony fragments and position of the prostate. High riding prostate suggests posterior urethral tears. • Urethral disruption should be considered when blood is noted at the meatus. • Vaginal exam for bleeding – may suggest bony fragments causing laceration. Implications of bleeding during pregnancy should be considered.

The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT: • abdominal pain and tenderness • early bacterial peritonitis • development of rebound, guarding and rigidity • hypotension and tachycardia • palpable mass and radiographic mass effect (may result from confined hemorrhage)

DIAGNOSTIC STRATEGIES • Hct: can be a delayed sign, should do serial. • WBC:  in stress, peritoneal irritation • Pancreatic enzymes: if normal, does NOT r/o pancreatic injury  amylase: EtOH, narcotics amylase & lipase: ischemia 2 hypotension both non-specific & non-sensitive for pancreatic injuries

Are abdo x-rays useful in trauma? Although plain abdominal films can demonstrate numerous findings, their place in acute trauma is limited. Because of spinal precautions, hemodynamic instability, time consuming or patient discomfort.

Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT : • pleural effusion • appearance of the nasogastric tube in the chest • appearance of bowel loops in the chest • elevation of the diaphragm • blurring of the diaphragm

Abdominal trauma