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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.

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abdominal trauma

ABDOMINAL TRAUMA

Mark Boyko EM

where to start

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
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
Abdominal Layers

Transversalis Fascia

Peritoneum

blunt trauma
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
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
Question
  • TRUE OR FALSE: In the setting of abdominal trauma, absent bowel sounds after 30 seconds of listening indicates bowel perforation

FALSE

question1
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
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’

question2
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

question3
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
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
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
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 labs1
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
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
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

question4
Question

FAST ultrasound is now called e-FAST… what does the ‘e’ stand for?

Extended…

Lung bases

fast ultrasound how good is it
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 ultrasound1
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
Diagnostic Peritoneal Taps

Question: What is considered a ‘positive’ peritoneal aspirate?

10 cc of frank blood

diagnostic peritoneal taps1
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
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
slide29
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
slide30
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
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
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
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
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 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
BLUNT ABDO TRAUMA:AN APPROACH

The Unstable Patient

vs

The Stable Patient

… it’s as easy as 1-2-3

the unstable patient
The UNSTABLE Patient

STEP 1. Is there peritonitis? YES or NO.

YES goes to the OR.

the unstable patient1
The UNSTABLE Patient

STEP 2. Do a FAST.

If positive If negative

To the OR Look for another area of injury

the unstable patient2
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
The STABLE Patient

STEP 1. Can you evaluate them? (poor GCS, intoxication)

YES NO

Do Phx CT Scan

the stable patient1
The STABLE Patient

STEP 2. Is there peritonitis?

YES NO

To the OR …do a FAST

the stable patient2
The STABLE Patient

STEP 3. Do a FAST.

If positive If negative

Get CT Scan Serial exam q12hrs

injury severity scale 0 75
“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
Take a breather…

Guinness World Record - Longest Time Waiting for a Bed at a Hospital?

take a breather1
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”.

question5
Question

Most commonly injured organ in penetrating trauma?

A) Liver

B) Spleen

C) Bowel

D) Kidney

E) Bladder

stab wounds
Stab Wounds
  • 3x more common than firearms, but firearms will kill more
  • Used to be ‘mandatory exploration’, this is changing
  • 70% of the time your peritoneum is violated, but only 25% require the OR
  • Any stab wound to the lower chest, back, flank or pelvis has entered the abdominal cavity until proven otherwise
stab wounds non operative management
Stab Wounds - Non operative Management
  • No peritonitis,
  • No evisceration,
  • No hemodynamic instability

…can be safely selected for non-operative care

gunshot wounds
Gunshot Wounds
  • Bullets do not move in straight lines, anything can be injured
  • Trauma surgeon will want to know type of gun, estimate of distance, number of shots, etc.
  • Look carefully in the folds (axilla, groin)
  • Count your bullet holes! Even is good, odd is bad.
imaging in penetrating trauma
Imaging in Penetrating Trauma
  • Plain films have a better role here than in blunt abdo trauma
  • Can give you an idea of bullet trajectory, or remains of steel implementation
question6
Question

TRUE or FALSE: FAST ultrasound has a role in penetrating trauma.

TRUE

fast in penetrating trauma
FAST in Penetrating Trauma
  • FAST is now being used for penetrating trauma.
  • A positive FAST has a positive predictive value of >90 percent, but a negative FAST does not rule out peritoneal violation.
  • Sensitivity 60-90% in early studies
dpa dpl
DPA/DPL
  • Known to have very high sensitivity for intrabdominal injury from gunshot wounds
  • 10,000 RBC/cc threshold gives SENS 96%
  • Only tells you if there is blood in the abdomen, doesn’t tell you which organ is affected

If normal CT --> Observe / discharge

ct scan1
CT Scan
  • Stab or Gunshot - SENS 97%, SPEC 98% with triple contrast, but a recent study shows only IV contrast approaches same numbers
an approach penetrating trauma
An APPROACH - Penetrating Trauma

2 BIG QUESTIONS:

1. Has the peritoneal lining been disrupted?

2. If so, is there organ injury?

an approach
An APPROACH

STEP 1. The following are DIRECT TO OR in penetrating trauma:

1. Hemodynamic Instability. Ensure you have ruled out an intrathoric cause for this ie hemothorax, pneumothorax, tamponade.

2. Peritoneal Signs. Strong NPV if totally normal. Grey area for ‘equivocal’ patients.

3. Evisceration. This one is obvious.

4. Diaphragmatic injury – left sided.

5. Frank GI Bleeding. Blood back from NG tube or frank hematemesis.

6. Implements in Situ. Do NOT remove this in the ER unless it is hindering your resuscitation effort.

7. Free air. Fairly non-specific finding, take it in context (have they had a recent laparotomy, is their an involved lung injury?)

an approach1
An APPROACH

STEP 2. Has the peritoneal lining been disrupted?

  • Free air on radiograph.
  • Local wound exploration.
  • FAST. Helpful if positive.
  • Laparoscopy

BOTTOM LINE: If you cannot confidently rule it out, assume it has been disrupted.

local wound exploration
Local Wound Exploration
  • Do we actually do this??
  • “Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds” -The American Journal of Surgery 2009
  • “Non-operative Management of Abdominal Gunshot Wounds” -Annals of Emergency Medicine 2004… “local wound exploration should not be used in gunshot wounds”.
an approach2
An APPROACH

STEP 3. Is there an injury that requires operative repair?

CT Scan

Normal CT --> Observe / discharge

non operative management of penetrating trauma
Non-operative Management of Penetrating Trauma
  • Gaining favour
  • A number of recent studies showing the use of CT Scan and serial physical exams can keep people out of the OR
  • Annals of Surgery 2001 Prospective Study – 1856 patients, 42% treated non-operatively -> decision made on Phx and CT, majority of these d/c home without an operation.
so in summary
So… In Summary

BLUNT TRAUMA

UNSTABLE PATIENT!

unstable
UNSTABLE

1. Is there peritonitis? YES or NO

2. Is there a positive FAST? YES or NO

3. Is there a positive DPA? YES or NO

CT Scan is your friend.

in summary
In Summary

BLUNT TRAUMA

STABLE PATIENT…

stable
STABLE

Relax….

1. Can you evaluate them? YES or NO

2. Is there peritonitis? YES or NO

3. Is there a positive FAST? YES or NO

in summary1
In Summary…

PENETRATING TRAUMA

UNSTABLE PATIENT!

unstable1
UNSTABLE

1. Do they have a ‘Direct to OR’ indication? YES or NO

2. Is there a positive FAST? YES or NO

3. Is there a positive DPA? YES or NO

Xray and CT Scan are your friends.

in summary2
In Summary…

PENETRATING TRAUMA

STABLE PATIENT…

stable1
STABLE

Relax…

1. Has the peritoneal lining been disrupted? YES or NO

2. If so, is there organ injury?

YES or NO

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