ABDOMINAL TRAUMA Mark Boyko EM
Where to Start? Review key aspects of abdo trauma. Important imaging modalities. An Approach to Blunt abdo trauma. An Approach to Penetrating abdo trauma
Anatomy The anterior abdomen is defined as that region between the anterior axillary lines from the anterior costal margins to the groin creases.
Abdominal Layers Transversalis Fascia Peritoneum
BLUNT TRAUMA • Most commonly MVA’s • Also involves fall from height, assaults, sports injuries • Can injure solid organs (liver, spleen) or hollow viscus (bowel)
How Good is our Physical Exam? • Accuracy only 60% • Serial exams q30min by same physician does improve detection rate somewhat • The most important thing to detect is peritonitis
Question • TRUE OR FALSE: In the setting of abdominal trauma, absent bowel sounds after 30 seconds of listening indicates bowel perforation FALSE
Question Which organ is most commonly injured in blunt abdominal trauma? A) Liver B) Spleen C) Bowel D) Pancreas E) Bladder
Splenic Injury - Grading System I - Hematoma, subcapsular <10% SA Capsular Lac <1cm II - Hematoma, subcapsular 10-50% SA; intraparenchymal <5cm Capsular Lac 1-3cm III - Hematoma, subcapsular >50% SA; intraparenchymal >5cm Capsular Lac >3cm (or parenchymal depth) IV - Hematoma ruptured into parenchyma Hilar Injury devascularizing spleen >25% V - Vascular hilar injury devascularing spleen 100%, or ‘Shattered’
Question • How soon will you see signs of retroperitoneal hemorrhage? A) 30 min B) 1-2 hrs C) 4-6 hrs D) 8-12 hrs E) >12 hrs
Question TRUE or FALSE: The ‘seat belt sign’ is a strong indicator of serious abdominal injury TRUE
The American Surgeon 1999 Feb;65(2):181-5. • Prospective Study of 410 patients, restrained MVC occupants, 77 had ‘seatbelt sign’. 23% with sign had serious intrabdominal injury vs 3% without. Have a high index of suspicion!
Physical Exam BOTTOM LINE:In the trauma patient, a ‘normal’ physical exam of the abdomen doesn’t equate to much. You NEED to do further testing.
Trauma Labs Can you name the complete list of trauma labs ordered at FMC? • CBC, lytes, Cr, Glucose • EtOH • PT/INR • Type & Screen • Urinalysis
Trauma Labs • WBC or Hct not particularly helpful in first few hours • Amylase/Lipase not helpful for pancreatic trauma • LFT’s can indicate trauma, but gives no indication of the severity. • BOTTOM LINE: Other than Hgb, your labs do not guide your clinical management
Imaging in Abdominal Trauma • Plain films generally have NO ROLE in acute abdominal trauma • What else do we have? • FAST ultrasound • Diagnostic Peritoneal Tap • CT Scan
FAST Ultrasound The real role of FAST ultrasound is to: A) Determine who needs a CT scan B) Determine who needs urgent laparotomy C) Determine extent of organ damage D) To look for babies E) To look cool
Question FAST ultrasound is now called e-FAST… what does the ‘e’ stand for? Extended… Lung bases
FAST Ultrasound - How Good is it? • 85% SENS for detecting ANY abdominal trauma • 97% SENS for detecting SURGICALLY SIGNIFICANT abdo trauma • 100% SENS for all FATAL injuries • Farahmand N, Sirlin CB, Brown MA, et al. Hypotensive patients with blunt abdominal • trauma: performance of screening US. Radiology 2005;235:436–43
FAST Ultrasound Advantages • Sensitivity at detecting 100cc fluid is 60-95% • No radiation Disadvantages • It is less sensitive and more operator-dependent than DPL in revealing hemoperitoneum • Cannot distinguish blood from ascites • Says nothing about solid organ damage; Chiu et al. showed 28% solid organ injury despite a normal FAST
Diagnostic Peritoneal Taps Question: What is considered a ‘positive’ peritoneal aspirate? 10 cc of frank blood
Diagnostic Peritoneal Taps DPA - The recovery of 10 cc of frank blood(or more) from the peritoneum is a strong predictor (90% PPV in blunt trauma) of intraperitoneal injury, and the procedure is then terminated. DPL - If aspiration findings are negative, lavage is conducted in which the peritoneal cavity is washed with saline. RBC count exceeding 100,000/cc is considered positive and generally specific for injury. Sensitivity 90%.
Diagnositic Peritoneal ‘Lavage’ • Is actually a 2 Step Process. Step 1. DPA (closed). • Patient supine • Landmark is 2 fingerwidths below umbilicus • Local freezing, puncture skin 30-degrees to the head • Seldinger technique to introduce a DPL catheter • Aspirate using 30cc syringe
DPA • Advantages • Highly accurate for hemoperitoneum (SENS 90-100%) • Most sensitive test for hollow viscus injury • Disadvantages • Invasive (complication rate 1-5%) • Time consuming (20 minutes) • False positives. Up to 25% non-therapeutic laparotomies
DPA • If 10cc frank blood or more is aspirated, you are done, patient needs to go to the OR. • If the DPA is negative, you proceed to Step 2…
Diagnostic Peritoneal Lavage Step 2. DPL. • Hook up 1L of Ringer’s to the peritoneal catheter, and squeeze into the abdomen. • Once infused, put the empty Ringer’s bag on the floor, and let it back-fill via gravity • Send off 10cc for analysis, if 100,000 RBC/cc it is positive
Is there still a role for DPA? • FAST has largely replaced DPA, likely due to ease of use. • However, 2 areas where still is warranted: • Hemodynamically unstable and an equivocal FAST • No FAST available • “DPL is safe, sensitive, and reduces the use of CT” (Journal of Trauma 2007)
FAST vs DPL • Journal of Trauma 2007.“Are Diagnostic Peritoneal Lavage or Focused Abdominal Sonography for Trauma Safe Screening Investigations for Hemodynamically Stable Patients After Blunt Abdominal Trauma? A Review of the Literature” • Screening diagnostic peritoneal lavage and selective CT is a safe diagnostic strategy for the investigation of blunt abdominal trauma. Further research is needed to determine the role of focused abdominal sonography for trauma scanning in diagnostic protocols. • Emerg Med Clin North Am.1999 Feb;17(1):63-75, viii. • The sensitivity of FAST has been reported as anywhere between 42% and 93% • The sensitivity of DPL for detecting significant intra-abdominal injury has been reported to range from 82% to 96% • Cochrane Review 2005 -“there is insufficient evidence to justify the use of ultrasound as part of the diagnosis of patients with abdominal injury… in terms of decreased mortality or diagnostic testing”
CT Scan • The imaging modality of choice in blunt abdominal trauma • SENS 92-96%, SPEC 97% (CAEP, Review Lavage) • The organ that brings down CT sensitivity is the pancreas – only 80% sensitive
CT Scan - Bowel Injury? • CT SENS for bowel injury >90%, enough to allow immediate d/c from ER (used to have lower sensitivity which would require monitoring even after negative CT) • Protocol: CT with IV contrast only is equivalent to CT with oral/IV contrast in trauma
BLUNT ABDO TRAUMA:AN APPROACH The Unstable Patient vs The Stable Patient … it’s as easy as 1-2-3
The UNSTABLE Patient STEP 1. Is there peritonitis? YES or NO. YES goes to the OR.
The UNSTABLE Patient STEP 2. Do a FAST. If positive If negative To the OR Look for another area of injury
The UNSTABLE Patient STEP 3. If no other obvious area of injury, do a DPA. If positive If negative To the OR … try and stabilize, get CT
The STABLE Patient STEP 1. Can you evaluate them? (poor GCS, intoxication) YES NO Do Phx CT Scan
The STABLE Patient STEP 2. Is there peritonitis? YES NO To the OR …do a FAST
The STABLE Patient STEP 3. Do a FAST. If positive If negative Get CT Scan Serial exam q12hrs
“Injury Severity Scale”0 -75 6 areas of the body: • Head & Neck • Face • Chest • Abdomen • Extremity • External • 6 options for injury: • Minor • Moderate • Serious • Severe • Critical • Unsurvivable
Take a breather… Guinness World Record - Longest Time Waiting for a Bed at a Hospital?
Take a breather… Guinness World Record - Longest Time Waiting for a Bed at a Hospital Tony Collins, United Kingdom 2001 - waited 77hrs, 30 min on a stretcher in a hallway. Diagnosis was “viral illness”.