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B lunt

B lunt. A bdominal. T rauma. Dr. Sean Wilde, PGY-3 (CCFP-EM) Aug 18 2011 Preceptor: Dr. Trevor Langhan. Game Plan. Stepwise approach to BAT The baseball diamond approach Adults only Intra-abdominal & GU trauma Classification by stability and patient evaluability Role of FAST

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B lunt

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  1. Blunt Abdominal Trauma Dr. Sean Wilde, PGY-3 (CCFP-EM) Aug 18 2011 Preceptor: Dr. Trevor Langhan

  2. Game Plan • Stepwise approach to BAT • The baseball diamond approach • Adults only • Intra-abdominal & GU trauma • Classification by stability and patient evaluability • Role of FAST • When can you avoid a CT

  3. 13% of all injuries are Abdominal Trauma Case mortality is 8% Most deaths are in blunt abdominal trauma Meet the Players…

  4. Motor Vehicle Collisions 50-75% of BAT

  5. Direct blows to the abdomen 15% (assaults and recreational activities)

  6. Falls from a height 6-9%

  7. Mechanisms • Abrupt Intra-abdominal pressure changes • Compression of abdominal contents • Acceleration-deceleration forces

  8. At Risk • Spleen • Liver • Small bowel • Retroperitoneum • Kidneys • Bladder • Colorectal • Diaphragm • Pancreas

  9. CHALLANGES Often multi-trauma • Altered LOC • Unreliable Physical Exam • Multiple diagnostic • tests • Significant miss of • intestinal and • pancreatic injuries

  10. Develop the BAT reflex Have a simple, step-wise approach to the management of the blunt abdominal trauma victim…

  11. CT ABDO/PELVIS STABLE, EVALUABLE PATIENT CT ABDO/PELVIS ? Physical exam finding ? +ve FAST ? Gross hematuria ? Micro hematuria w rapid decel injury ? Other CTable injury YES Beware: hollow viscous, diaphragm, pacreatic inj. (CT poor) YES NO Consider retrograde urethrogram/ cystogram Is stable patient reliably evaluable? ? peritonitis NO ? peritonitis ? +ve FAST ? Hematuria STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST UNSTABLE PATIENT TO THE O.R. Fluid, transfusion ? Unclear exam ? –ve FAST Consider: ~mech of injury ~associated injury ~clinical gestalt normal ? Stable CT result BAT ~Consider other sources of blood loss (pelvis, retroP) ~Consider DPA/DPL abnormal Y N Observation Serial exams ARRESTING? CONSULT SEND HOME

  12. ABC’s in BAT • ABC / OIL • Prioritize the injuries • Airway > Chest > Abdomen > Head > GU • Don’t forget the Abdomen in multi-trauma! • Feel the Belly! • More than once • FAST scan is part of primary survey • Do it BEFORE the log roll.

  13. The Baseball Diamond Approach to BAT • Stability • Arresting, unstable or stable? • OR Red flags • In the unstable vs stable patient • Initial resuscitation • To CT or not to CT • Is the patient evaluable? • What findings mandate/avoid a CT? • When is DPL useful? • Reassuring findings • going for home

  14. Case 1 • 40yo male, MVC • Restrained driver • Passenger fatality • Unconscious at scene • Cardiac arrest pulling into ambulance bay after 2 litres NS • Diffuse chest and abdominal bruising with distended abdomen • No major open injuries • CPR in progress, asystole on monitor

  15. I would: A) Crack the chest for open cardiac massage B) ATLS/ACLS and 2 fridges of blood C) ED Laparotomy D) Do nothing (“He’s dead Jim”) E)

  16. Plan: Mortality after BAT arrest is dismal; worse than penetrating or chest trauma Doing nothing is a valid option*

  17. However, if you do go there…. • Treat emergencies of the chest • Open Cardiac resuscitation • If you get a pulse: • Cross-clamp aorta • Straight to OR

  18. Fluid Resuscitation • Colloids • NS, Ringer’s • Blood Early • Massive Transfusion Protocols • 6:6:1

  19. TO THE O.R. UNSTABLE PATIENT Fluid, transfusion ? Stable BAT Y N ARRESTING? • Ongoing hemodynamic instability after initial fluid? • Stop at 1st base! • Stable vitals? • Head towards 2nd.

  20. Case 2 • 29y F, thrown from bike in motocross accident • GCS 11-14, fluctuating • Non-ambulatory at scene • Full spinal precautions • HR 135, BP 70/55, O2 95% on 2L NP • Cries in pain when transferred to bed • Hurts “everywhere!” • Now what?

  21. Trauma Survey • Chest unremarkable • Diffuse mild tenderness to abdomen • Pelvis stable but painful • FAST –ve • Long bones look OK • Lots of pain to RLQ/right hip on log roll • Resuscitation • Brief improvement in vitals/GCS with fluid, then rapid decline • Getting more drowsy • Hg 105 on ABG

  22. Too unstable for CT! Unstable BAT patient Fluid/Blood Resuscitation ? Peritonitis ? Positive FAST ? Hematuria To the OR YES To any • NO • Exam unclear • FAST negative • Urine bland • Too unstable for imaging Positive Consider DPA/DPL Negative Consider other sources of blood loss and shock ? retroperitoneal hematoma Pelvic # Interventional Radiology

  23. Case cont… • FAST is negative • No peritonitis • Microscopic hematuria after catheter • Non displaced pelvic fracture on x-ray • But the belly seems more tender than earlier…

  24. FAST Facts • Poor sensitivity • 200cc fluid for positive scan • Cannot use a negative scan alone to rule out need for surgery • Good specificity • For free abdominal fluid • Blood vs Urine

  25. DPL? • Unstable, multi-injured patient with questionable abdominal source • Replace serial abdominal exam in head injured patient • Post normal CT with ongoing high suspicion of the abdomen • Remote area where CT unavailable- i.e. O.R. before transport?

  26. ? peritonitis ? +ve FAST ? Hematuria UNSTABLE PATIENT TO THE O.R. Fluid, transfusion ? Unclear exam ? –ve FAST ? Stable BAT ~Consider other sources of blood loss (pelvis, retroP) ~Consider DPA/DPL Y N ARRESTING?

  27. Rounding 1st base Hemodynamically stable BAT patient ASK: Can I reliably evaluate this patient? GCS Head injury Intoxication Distracting injury Drugs NO = go to CT YES = arrive at 2nd base! STABLE, EVALUABLE PATIENT CT ABDO/PELVIS YES NO Is stable patient reliably evaluable? Fluid, transfusion ? Stable BAT

  28. Case 3 • 45y M kicked in the stomach 7 hours ago • Ongoing discomfort • Vitals normal and stable • Generalized abdo pain on palpation • No peritonitis • No guarding • No visible bruising • Urine clean • Next?

  29. FAST To CT Scan- Lacerated Spleen

  30. CAT Scan in BAT Very good sensitivity and specificity Normal CT scan can be considered very reassuring Critical management decisions

  31. Oral Contrast? • Does not increase detection of HVI • Impractical/Risky (NG feeds on spine board) • Local trauma surgeons rarely use it • Negative CT- Consider missed: • GI (hollow viscous) injuries • Diaphragmatic injuries • Pancreatic injuries • Serial exams and CT Scans as indicated will catch most.

  32. Stable BAT patient with reliable exam Diffuse Peritonitis * Physical exam * FAST * Check Urine * Consider mechanism Surgery (+/- CT) Any +ve Physical Exam Finding OR Positive FAST OR Gross hematuria OR Deceleration injury with Microscopic hematuria OR Any other injury requiring CT Abdo CT Scan Normal physical exam Negative FAST Normal urine Low risk Mech of injury Consider retrograde urethrogram Observation vs Discharge

  33. Abdominal seatbelt sign: • IA injury rate 23% with, 3% without

  34. Vertebral (Chance) #, mesenteric tears

  35. BAT Physical Exam +ves • Abdominal Seatbelt sign • Pain with guarding • Any peritoneal findings • Remember value of repeat exams!!!

  36. CT ABDO/PELVIS STABLE, EVALUABLE PATIENT ? Physical exam finding ? +ve FAST ? Gross hematuria ? Micro hematuria w rapid decel injury ? Other CTable injury YES • Rounding 2nd base to 3rd • Avoiding a CT so far… • What’s between you and home plate? Consider retrograde urethrogram/ cystogram NO STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST

  37. Case 3 the remix… • As before, kicked in stomach, ongoing pain. • Vitals stable • This time all investigations negative, including FAST • What now?

  38. STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST Consider: ~mech of injury ~associated injury ~clinical gestalt Observation Serial exams CONSULT SEND HOME 3rd Base to Home Plate • Consider mechanism, clinical gestalt • Not worried? • D/C with FU • Worried? • Can still CT • Or Observation: serial abdominal exams, FAST, blood work • Second opinion

  39. Holmes, 2009. Low risk Clin Pred Rules in BAT If none of: • GCS <14 • Abdominal/costal margin tenderness • Hematuria • Hematocrit < 30% • Femur fracture • CHXR trauma findings Negative predictive value of 99% for intra-abdominal injury

  40. The Bare Minimum… Serial abdominal exams (at least 2) Negative FAST Clean Urine

  41. Case 4 • 29y M fell 12ft off “scissor lift.” • Landed on his bottom • Stable, alert, c/o sore buttocks • Head/spines cleared • Abdomen non-tender • FAST negative • Urine dips 3+ blood

  42. GU Trauma • Blood at meatus • High riding/boggy prostate • Unable to void • Hematuria (esp gross)

  43. Retrograde Urethrogram in suspected GU trauma (Pre-catheter) Post cath: Follow-up CT and Cystogram (Upper GU Trauma)

  44. CT ABDO/PELVIS STABLE, EVALUABLE PATIENT CT ABDO/PELVIS ? Physical exam finding ? +ve FAST ? Gross hematuria ? Micro hematuria w rapid decel injury ? Other CTable injury YES Beware: hollow viscous, diaphragm, pacreatic inj. (CT poor) YES NO Consider retrograde urethrogram/ cystogram Is stable patient reliably evaluable? ? peritonitis NO ? peritonitis ? +ve FAST ? Hematuria STABLE: NORMAL PHYS EXAM, -ve URINE, -ve FAST UNSTABLE PATIENT TO THE O.R. Fluid, transfusion ? Unclear exam ? –ve FAST Consider: ~mech of injury ~associated injury ~clinical gestalt normal ? Stable CT result BAT ~Consider other sources of blood loss (pelvis, retroP) ~Consider DPA/DPL abnormal Y N Observation Serial exams ARRESTING? CONSULT SEND HOME

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