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Abdominal Trauma. Nestor Nestor, M.D., M.Sc. January 17, 2007. The Plan. Abdominal Anatomy Mechanisms of Injury Common Pathology Evaluation Management. Part 1: Abdominal Anatomy. Abdominal Anatomy Basics. ABC’s Many organs receiving substantial blood flow

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abdominal trauma

Abdominal Trauma

Nestor Nestor, M.D., M.Sc.

January 17, 2007

the plan
The Plan
  • Abdominal Anatomy
  • Mechanisms of Injury
  • Common Pathology
  • Evaluation
  • Management
abdominal anatomy basics
Abdominal Anatomy Basics
  • ABC’s
  • Many organs receiving substantial blood flow
  • Potential spaces that can hide hemorrhage
  • Hollow organ damage> Peritonitis
abdominal anatomy basics1
Abdominal Anatomy Basics
  • ABC’s
  • Many organs receiving substantial blood flow
  • Potential spaces that can hide hemorrhage
  • Hollow organ damage> Peritonitis
abdominal anatomy basics2
Abdominal Anatomy Basics
  • ABC’s
  • Many organs receiving substantial blood flow
  • Potential spaces that can hide hemorrhage
  • Hollow organ damage > Peritonitis
abdominal anatomy basics3
Abdominal Anatomy Basics
  • ABC’s
  • Many organs receiving substantial blood flow
  • Potential spaces that can hide hemorrhage
  • Hollow organ damage > Peritonitis
abdominal injuries
Abdominal Injuries
  • Blunt vs. Penetrating
  • Often both occur simultaneously
  • Blunt is the most common mechanism in US
blunt abdominal trauma
Blunt Abdominal Trauma
  • Direct impact or movement of organs
  • Compressive, stretching or shearing forces
  • Solid Organs > Blood Loss
  • Hollow Organs > Blood Loss and Peritoneal Contamination
  • Retroperitoneal > Often asymptomatic initially
blunt abdominal trauma1
Blunt Abdominal Trauma
  • Direct impact or movement of organs
  • Compressive, stretching or shearing forces
  • Solid Organs > Blood Loss
  • Hollow Organs > Blood Loss and Peritoneal Contamination
  • Retroperitoneal > Often asymptomatic initially
blunt abdominal trauma2
Blunt Abdominal Trauma
  • Direct impact or movement of organs
  • Compressive, stretching or shearing forces
  • Solid Organs > Blood Loss
  • Hollow Organs > Blood Loss and Peritoneal Contamination
  • Retroperitoneal > Often asymptomatic initially
blunt abdominal trauma3
Blunt Abdominal Trauma
  • Direct impact or movement of organs
  • Compressive, stretching or shearing forces
  • Solid Organs > Blood Loss
  • Hollow Organs > Blood Loss and Peritoneal Contamination
  • Retroperitoneal > Often asymptomatic initially
blunt abdominal trauma4
Blunt Abdominal Trauma
  • Direct impact or movement of organs
  • Compressive, stretching or shearing forces
  • Solid Organs > Blood Loss
  • Hollow Organs > Blood Loss and Peritoneal Contamination
  • Retroperitoneal > Often asymptomatic initially
liver lacerations
Liver Lacerations

I. Subcapsular Hematoma <10% Surface Area

II. Subcapsular Hematoma 10-50%

III. Subcapsular Hematoma >50%

IV. Parenchymal Disruption of 25-75%

V. Parenchymal Disruption of >75%

VI. Liver Avulsion

splenic lacerations
Splenic Lacerations

I. Subcapsular Hematoma <10% Surface Area

II. Subcapsular Hematoma 10-50%

III. Subcapsular Hematoma >50%

IV. Laceration producing devascularization of >25% of the spleen

V. Shattered Spleen

evaluation be suspicious
Evaluation: Be Suspicious
  • Mechanism
  • Vitals
  • Symptoms
  • Associated Injuries
  • Elderly or co-morbidities
  • Distracting injuries
  • Decreased MS/intoxication
techniques for evaluation
Physical Exam

Serial exams in awake, alert and reliable pt

Plain Films

Abd films little or no use, pelvic are the standard

Screening

Diagnostic Peritoneal Lavage (DPL)

Ultrasound:FAST (serial exams)

Techniques for Evaluation
techniques for evaluation1
Physical Exam

Serial exams in awake, alert and reliable pt

Plain Films

Abd films little or no use, pelvis are the standard

Screening

Diagnostic Peritoneal Lavage (DPL)

Ultrasound:FAST (serial exams)

Techniques for Evaluation
techniques for evaluation2
Physical Exam

Serial exams in awake, alert and reliable pt

Plain Films

Abd films little or no use, pelvis are the standard

Screening

Diagnostic Peritoneal Lavage (DPL)

Ultrasound: FAST (serial exams)

Techniques for Evaluation
techniques for evaluation3
Organ Specific Dx

Only CT

Also evaluates retroperitoneum

Expensive

Radiation

Ex Lap

Laparotomy gold standard for evaluation

Concomitant treatment

Retroperitoneum difficult to explore/assess

Techniques for Evaluation
techniques for evaluation4
Organ Specific Dx

Only CT

Also evaluates retroperitoneum

Expensive

Radiation

Ex Lap

Laparotomy is the gold standard for evaluation

Concomitant treatment

Retroperitoneum difficult to explore/assess

Techniques for Evaluation
penetrating trauma evaluation
Penetrating Trauma Evaluation
  • Mandatory exploration abandoned
  • No digital exploration or contrast studies
  • Inspect wound to determine if there is violation of the fascia
  • Difficult to assess stab wound trajectory
  • Determine if gunshot traversed the peritoneal cavity
management
Management
  • ABC’s
  • Fluid resuscitate
  • To lap or not to lap?
  • Unstable (with no other reason)
  • Free air/peritonitis (antibiotics)
  • Unexplained free fluid
  • Many splenic/liver lacs managed non-operatively or by VIR
penetrating flank and buttock injuries
Penetrating Flank and Buttock Injuries
  • Potential for peritoneal and/or retroperitoneal injury
  • Similar evaluation and management to abdominal
  • Buttock injuries may also reach peritoneal and/or retroperitonal structures
gu trauma
GU Trauma
  • 2-5% of adult traumas
  • Vast majority blunt mechanisms
  • 80% renal injuries
  • 10% bladder injuries
  • Abnormalities (tumor, hydro) increase susceptibility
  • Rarely require immediate intervention
evaluation
Evaluation
  • Rectal - high riding prostate
  • Perineum - ecchymosis, lacs
  • Genitals - meatal/vaginal blood
  • Difficult catheter placement (may need suprapubic)
  • UA – hematuria (poor correlation to degree of injury)
evaluation1
Evaluation
  • U/S and Plain films of little use
  • CT is the superior imaging modality
  • Careful with contrast (nephropathy)
  • Angiography remains the gold standard
  • IVP/Cystoscopy less useful in the ED
gu injuries the kidneys
GU Injuries: The Kidneys
  • Kidneys are well protected
  • Most commonly bruised
  • Pts with a shattered kidney become rapidly unstable
  • Renal vascular injuries may result in thrombosed vessels
gu injuries the kidneys1
GU Injuries: The Kidneys

Operative management for:

  • uncontrolled hemorrhage
  • Penetrating injuries
  • Multiple lacs
  • Shattered kidney
  • Avulsed vessels
gu injuries the bladder
GU Injuries: The Bladder
  • Contusion
  • Rupture: Intra vs. Extraperitoneal
  • Extraperitoneal presents with pain, hematuria and inability to void
  • Urethral injuries: Anterior vs. posterior
  • No Foley for urethral injuries
in summary
In Summary...
  • Basic knowledge of anatomy necessary for initial assessment of abdominal trauma
  • Peritoneal vs. Retroperitoneal
  • Blunt vs. Penetrating
  • Don’t miss GU injuries