Abdominal Trauma Chapter 5
Objectives • Identify key anatomic features of the abdomen • Describe blunt and penetrating injury patterns • Describe the evaluation of the patient with suspected abdominal injury
Objectives • Identify and apply the most appropriate diagnostic and therapeutic procedures • Discuss acute management of pelvic fractures
Key questions • What priority is abdominal trauma in the management of the multiply injured patient? • Why is the mechanism of injury important? • How do I know if shock is the result of an intra-abdominal injury?
Key questions • How do I determine if there is an abdominal injury? • Who warrants a celiotomy (laparotomy)? • How do I manage patients with pelvic fractures?
External anatomy Flank Do not forget the back!
Internal Abdominal Regions Upper peritoneal cavity Lower peritoneal cavity Pelvic cavity Do not forget the retroperitoneal cavity.
Abdominal Trauma • What is one of the leading causes of preventable mortality?
Abdominal trauma priority? • Head and abdominal trauma? • Head, chest and abdominal trauma? • Head, chest, abdominal and extremity trauma? • Head, chest, abdomen, extremity and pelvic trauma?
Mechanism of injury • Why is it important to know?
Blunt force • How does it injure? • Compression • Crushing • Shearing • Decelerations • What organs are commonly injured? • Spleen • Liver • Small bowel
Penetrating trauma • How does it injure? • Stab: low energy • Lacerations • Gunshot: high energy • Transfer of kinetic energy • What organs are commonly injured? • Low energy: liver, small bowel, diaphragm, colon • High energy: small bowel, colon, liver, vascular
Assessment: History • Penetrating: • Weapon • Distance • Number of wounds • Blunt: • Speed • Point of impact • Intrusion • Safety devices used • Position • ejection
Assessment: Physical exam • Inspection • Auscultation • Percussion • Palpation
Assessment • Stab wound: • How do I evaluate and manage the abdomen of a patient with an anterior abdominal, lower chest, flank, or back stab wound? • Penetrating injuries • How do I evaluate and manage perineal, rectal, vaginal or gluteal penetrating injuries? • Gunshot wound • How do I evaluate and manage the abdominal GSW?
Abdominal bleeding causing shock • Evidence of abdominal injury by mechanism, history or evaluation • Interventions: • Gastric tube relieves distention, decompresses stomach before DPL • Urinary catheter monitors urinary output, decompresses bladder before DPL • Laboratory tests • X-ray studies, contrast studies
Special studies in Blunt trauma *Operator dependent
Diagnostic studies • Penetrating: • Suspect if hypotensive, retroperitoneal injury, peritonitis • Lower chest wounds, anterior abdominal stab wounds, back and flank stab wounds • Exploration, CT, DPL, serial exams • Blunt trauma: • Suspect if dropping BP, free air, diaphragmatic rupture, peritonitis • Operative exploration, CT
Pelvic fractures • Mechanism • AP compression • Lateral compression • Vertical shear • Significant force • Associated injuries • Pelvic bleeding
Pelvic fractures • Assessment • Inspection • Palpate prostate • Pelvic ring: leg length discrepancy, external rotation, pain on palpation of bony pelvic ring • Management • Fluid resuscitation • Determine if open or closed fracture • Determine associated injuries • Determine need for transfer • Splint pelvic fracture
Summary • ABCDEs and early surgical consultation • Evaluation and management vary with mechanism and physiologic response • Repeated exams and diagnostic studies • High index of suspicion • Early recognition/prompt laparoscopy