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Abdominal trauma PowerPoint Presentation
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Abdominal trauma

Abdominal trauma

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Abdominal trauma

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  1. Abdominal trauma Role of CT Dr. Ahmed Refaey Consultant Radiologist Riyadh Military Hospital MBBCh, MS, FRCR

  2. Format of the lecture • Categorization of abdominal trauma patients • CT technique • CT findings • Illustrated cases

  3. Categories of abdominal trauma patients • Category A - hemodynamically unstable patients • Category B - hemodynamically stable patients • Category C - patients with hematuria

  4. Category A“hemodynamicallyunstable” • Need rapid clinical evaluation and immediate resuscitation with volume replacement • If not responding, they should go immediately to ORwithout imaging • If they respond ( become hemodynamically stable )-- Category B

  5. Category B“hemodynamically stable” • High clinical suspicion of intra-abdominal injury ------ CT not U/S • Low clinical suspicion of intra-abdominal injury ------ U/S not CT

  6. High clinical suspicion of intra-abdominal injury

  7. don’t ask forU/S - miss 25% of liver injuries - miss 62 % of splenic injuries - most renal injuries - all pancreatic injuries - all mesenteric injuries - all gut injuries - high proportion of retroperitoneal hematoma

  8. Low clinical suspicion of intra-abdominal injury

  9. U/S • If -ve ------- > release the patient from observation * If +ve ----- CT

  10. Category C“ patient withhematuria” • CT cystograhy

  11. Categories of blunt abdominal trauma • Category A - hemodynamically unstable patients * no radiological imaging • Category B - hemodynamically stable patients * CT – if high suspicion * US – if low suspicion • Category C - patients with hematuria * CT cystography

  12. CT technique

  13. CT in blunt abdominal trauma with or without oral contrast ? • Oral contrast is unnecessary in CT evaluation in patients with acute blunt abdominal trauma

  14. Why no oral contrast ?

  15. Extravasation of oral contrast in bowel perforation -------- 0 % - 19 % • Pneumopertoneum -------- 50 % * - small perforations may seal quickly and prevent extravasation of contrast and / or air that could then be detected by CT

  16. Time delay to diagnosis • Long transit time  non opacification of distal loops • Aspiration of gastric contrast contents with subsequent pulmonary toxic effects • Interference with the diagnosis of contrast blush

  17. Oral contrast is unnecessary in CT evaluation in patients with acute blunt abdominal trauma • 96. Allen TL, Mueller MT, Bonk RT, et al. Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma. J Trauma 2004; 56(2):314-322.

  18. Is pneumoperitoneum diagnostic of bowel injury? • No it is not diagnostic of bowel injury, since air transmitted from the chest in pneumothorax is the most common cause of intraperitoneal air in a trauma patient

  19. The sensitivity of CT scan with OC for detection of bowel injuries does not significantly differ from CT without OC • Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography. Am J Surg. 1993;166:680-685 • Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994;168:670-675.

  20. Trauma protocol

  21. Blunt trauma • No oral contrast • Venous phase ----- 70 sec • Delayed scan if injury present --- 3-5 min

  22. CT findings

  23. The findings to look for • Hemoperitoneum • Contrast blush • Laceration • Hematomas • Contusion • Pneumoperitoneum • Devascularization of organs • Subcapsular hematoma

  24. * Laceration : linear shaped hypodense lesion * Hematoma : oval or round hypodense areas * Contusion : vague ,ill-defined hpodense area , that is less perfused

  25. Contrast blush • An area of high density compared to the nearby vessel representing active arterial extravasation

  26. Illustrated cases

  27. Splenic injuries

  28. Splenic laceration • hemoperitoneum • No contrast blush …managed non-operatively

  29. Lacerations Hematoma Hemoperitoneum No contrast blush .. Depending on the clinical condition , the patient will be managed

  30. Hemoperitoneum • Laceration • Hematoma • Contrast blush .. Operative management

  31. Liver injuries

  32. Green arrow: hematoma Blue arrow : contusion Yellow arrow: laceration hemoperitoneum

  33. Hematoma • hemoperitoneum • Contrast blush … managed operatively

  34. Does the presence of contrast blush necissetate operative interference ? • No It depends on if it is associated with hemoperitoneum or no

  35. Large subcapsular hematoma • Contrast blush • No hemoperitoneum … Managed non-operatively

  36. Contrast extravasation is of great importance especially if it is associated with hemoperitoneum

  37. Splenic contusion with contrast blush

  38. Laceration • hematoma

  39. Lacerations Hematoma Hemoperitoneum Contrast blush Managed operatively

  40. Avulsed Rt hepatic vein Perforated duodenum

  41. Pancreas

  42. Pancreatic injury • Rarely an isolated injury, since the pancreas is protected by the liver, spleen and the bony thorax • Usually part of a” package injury “

  43. Isolated injury

  44. Left sided package injury