ABDOMINAL TRAUMA

1. ABDOMINAL TRAUMA USAF CSTARS Baltimore University of Maryland Medical Center R A Cowley Shock Trauma Center

2. OBJECTIVES • Comprehend abdominal anatomy • Understand diagnostic modalities used in the evaluation of abdominal trauma • Understand injury patterns in penetrating and blunt abdominal trauma • Familiarization with evaluation and treatment of specific abdominal organ injuries

3. EPIDEMIOLOGY • Blunt Abdominal Trauma • Spleen: 40-55% • Liver: 35-45% • Small Bowel: 5-10% • Penetrating Abdominal Trauma • Liver: 40% • Small Bowel: 30% • Diaphragm: 20% • Colon: 15%

4. EPIDEMIOLOGY • Blunt Trauma • Compression or Crushing • Shearing • Penetrating Trauma • Low Velocity: Laceration or cutting • High Velocity • Laceration or cutting • Cavitation

5. ANATOMY • External • Anterior abdomen • Flank • Back • Internal • Peritoneal cavity • Pelvic cavity • Retroperitoneum

6. ANATOMYPENETRATING INJURY • Anterior Abdomen • Below nipples • Above symphysis pubis • Between posterior axillary lines • Back • Below scapular tips • Above sacrum

7. INITIAL EVALUATION • Primary Survey • ABCs • Cardiac monitor and pulse oximeter • FAST • Concurrent resuscitation • Secondary survey • NGT • Foley Catheter

8. PHYSICAL EXAM • External Signs (e.g. contusions, seat belt, wounds, etc.) • Abdominal Exam • Perineum/Rectum • Roll the patient – check the back!!

9. DIAGNOSTIC EVALUATION • FAST • DPL • CT SCAN

10. FAST • Indications • Hypotensive • Document abdominal fluid • Advantages • Rapid • No transport required • Noninvasive • Repeatable • Disadvantages • Operator-dependent • Low specificity • Distortions by bowel gas, subcutaneous air, obesity • Misses diaphragm, bowel, pancreatic injuries

11. DPL • Indications • Hypotensive • Document bleeding, bowel injury, biliary injury • Advantages • Most Sensitive • Rapid • No transport required • Disadvantages • Invasive • Low specificity • Misses diaphragm and retroperitoneum

12. CT SCAN • Indications • Stable patient • Document organ injury • Advantages • Most specific • High sensitivity • Disadvantages • Increased cost and time • Transport required • Misses diaphragm and bowel injuries

13. PENETRATING ABDOMINAL INJURY • Stab Wound • Wound Exploration • Exploratory Laparotomy • Laparoscopy • Serial Physical Exams • Gunshot Wound • Exploratory Laparotomy • CT Scan

14. STAB WOUNDS • Local Exploration • Stable patient • Evaluation for peritoneal cavity intrusion • Use of CT Scan • Exploratory Laparotomy • Unstable patient, peritonitis, evisceration • Evidence of peritoneal cavity intrusion (e.g. positive DPL, positive FAST, etc.)

15. STAB WOUNDS • Laparoscopy • Evaluation of intra-abdominal injury • Specific role undefined • Serial Physical Exams • Asymptomatic patient • Positive local wound exploration • Flank or back stab wounds

16. GUNSHOT WOUNDS • Exploratory Laparotomy • Symptomatic or Asymptomatic patients • Path transverses abdomen, pelvis, or retroperitoneum • Stable or unstable patients • CT Scan • Asymptomatic patient • Stable patient • Flank or back wound to evaluate path of injury

17. BLUNT ABDOMINAL INJURY • Diaphragm • Duodenum • Pancreas • GU • Stomach, Small Bowel & Colon • Rectum & Perineum • Solid Organ Injury

18. DIAPHRAGM • High index of suspicion • Blunt injury = Large tear • Penetrating injury = Small hole • Most common on Left side • Diagnosis: CXR, CT Scan, GI Study • Treatment: Operative Repair

19. DUODENUM • High index of suspicion • Frontal impact, unrestrained OR direct abdominal blow • Diagnosis: Retroperitoneal air, CT Scan, abdominal exam • Treatment: Operative exploration/repair as indicated • Untreated: High morbidity/mortality

20. PANCREAS • High index of suspicion • Direct abdominal blow or compression by seatbelt against vertebral column • Diagnosis: Retroperitoneal air/fluid, CT Scan, abdominal exam, persistently elevated amylase • Treatment: Operative exploration/repair as indicated • Untreated: High morbidity/mortality

21. GENITOURINARY • Kidneys • Ureters • Bladder

22. KIDNEYS • GU eval for: • Gross hematuria • Microscopic hematuria + • Penetrating wound • Hypotension • Other abdominal injuries • Flank/back contusions, hematomas • Eval: CT Scan, Cystogram, IVP, Angiogram • Treatment • Operative Exploration/Repair • Angiographic Embolization • Observation

23. URETERS • GU eval for: • Gross hematuria • Microscopic hematuria + • Penetrating wound • Hypotension • Other abdominal injuries • Flank/back contusions, hematomas • Eval: CT Scan/Cystogram, IVP • Treatment • Operative Exploration/Repair • Ureteral Stents

24. BLADDER • GU eval for: • Gross hematuria • Microscopic hematuria + • Penetrating wound • Hypotension • Other abdominal injuries • Flank/back contusions, hematomas • Eval: CT Scan/Cystogram, IVP • Treatment • Extraperitoneal: Foley catheter drainage • Intraperitoneal: Operative repair

25. STOMACH, SMALL BOWEL & COLON • Clues • Seat belt sign • Chance fracture • Diagnosis: Exam, CT Scan, DPL • Treatment: Operative Exploration/Repair • Missed diagnosis/Delayed therapy: Increased morbidity/mortality

26. RECTUM & PERINEUM • Associations • High shear forces • Pelvic fracture • Diagnosis: Rectal/perineal exam, Proctosigmoidoscopy • Treatment • Debridement • Distal Washout • Drainage • Diversion

27. SOLID ORGAN INJURY • Most common in blunt and penetrating • Diagnosis: CT Scan most specific • Treatment • Operative • High grade injury • Unstable patient • Continued hemorrhage • Brain injury • Nonoperative • Low grade injury • Stable patient • Able to follow abdominal exam

28. SUMMARY • Abdominal Anatomy • Diagnostic Modalities • Stable patient • Unstable patient • Penetrating versus Blunt • Specific organ injuries

29. QUESTIONS ?