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Abdominal trauma. PRESENTED BY: Dr Louza Alnqodi , R3. outlines. Background Clinical assessment of pt with blunt , penetrating abdominal injuries Diagnostic tools Clinical approach Conclusion. R1. Which of the following does not cause a falsely +ve DPL? * Abdominal wall hematoma

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abdominal trauma

Abdominal trauma

PRESENTED BY:

Dr LouzaAlnqodi, R3

outlines
outlines
  • Background
  • Clinical assessment of pt with blunt , penetrating abdominal injuries
  • Diagnostic tools
  • Clinical approach
  • Conclusion.
slide3
R1
  • Which of the following does not cause a falsely +ve DPL?

*Abdominal wall hematoma

*inadequate homeostasis

*pelvic #

*retroperitoneal injury

slide4
R1
  • Which of the following does not cause a falsely +ve DPL?

*Abdominal wall hematoma

*inadequate haemostasis

*pelvic #

retroperitoneal injury

slide5
R2
  • Criteria for a +ve DPL include all of the following except:

*initial aspiration of at least 50ml gross blood

*>100,000 RBC in blunt trauma

*>5000 RBC in gunshot or penetrating low chest wound.

*presence of bile, bacteria or meat/vegetable fibers

slide6
R2
  • Criteria for a +ve DPL include all of the following except:

initial aspiration of at least 50ml gross blood

*>100,000 RBC in blunt trauma

*>5000 RBC in gunshot or penetrating low chest wound.

*presence of bile, bacteria or meat/vegetable fibers

slide7
R3

During the evaluation of a trauma patient, an upright CXR showed gastric bubble shifted to the rt .

No free air is present. What is the main concern?

*bowel perforation

*gastric injury

*retroperitoneal hematoma

*splenic injury

slide8
R3

During the evaluation of a trauma patient, an upright CXR showed gastric bubble shifted to the rt .

No free air is present. What is the main concern?

*bowel perforation

*gastric injury

*retroperitoneal hematoma

*splenic injury

slide9
R4
  • All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one?
  • *bowel protrusion or evisceration
  • *evidence of diaphragmatic injury
  • *indeterminate local wound exploration
  • Peritoneal irritation on physical examination
  • Significant GI bleeding
slide10
R4
  • All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one?
  • *bowel protrusion or evisceration
  • *evidence of diaphragmatic injury
  • *indeterminate local wound exploration
  • Peritoneal irritation on physical examination
  • Significant GI bleeding
slide11
R5
  • A 25 yr old male presents with a stab wound to the upper abdomen. Vital signs are stable. The abdomen is not distended, soft, non-tender. Bowel sounds are present. Upright CXR does not demonstrate a Penumothorax or free air under diaphragm. What should the next step be?

*evaluation of the peritoneal entry by local wound exploration

*performing DPL

*Proceeding directly to Laprotomy

*suturing of the wound and discharging the pt with clear instruction.

slide12
R5
  • A 25 yr old male presents with a stab wound to the upper abdomen. Vital signs are stable. The abdomen is not distended, soft, non-tender. Bowel sounds are present. Upright CXR does not demonstrate a Penumothorax or free air under diaphragm. What should the next step be?

*evaluation of the peritoneal entry by local wound exploration

*performing DPL

*Proceeding directly to Laprotomy

*suturing of the wound and discharging the pt with clear instruction.

anatomy
anatomy
  • Anterior abdomen
  • flank
  • Back
  • intraperitoneal contents
  • Retroperitoneal space contents
  • Pelvic cavity contents
slide14

Anterior abdomen:

trans-nipple line, , anterior axillary lines, inguinal ligaments and symphysis pubis.

  • flank:

anterior and posterior axillary line ;sixth intercostal to iliac crest

  • Back:

posterior axillary line; tip of scapula to iliac crest

slide15

Peritoneal cavity:

upper-diaphragm, liver, spleen, stomach, and transverse colon; lower-small bowel, sigmoid colon

  • Retroperitoneal space:

aorta, inferior vena cava, duodenum, pancreas, kidneys, ureters,ascending and descending colons

  • Pelvic cavity:

rectum, bladder, iliac vessels and internal genitalia

mechanism
mechanism
  • Blunt trauma:

MVC

Seatbelt injury

fall from ht

crash injury

sport injury

  • Penetrating injuries.
slide17

Blunt abdominal injuries carry a greater risk of morbidity and mortality than peneterating abdominal injuries.

slide18
associated with severe trauma to multiple intraperitoneal organs and extra-abdominal systems
  • altered mental status, intoxication
  • Peritoneal signs are often subtle and may be obscured by other painful injuries
  • Up to 20% of patients with hemoperitoneum have benign abdominal exams on initial presentation.
blunt injury
Blunt injury

Spleen (40-55%)

Liver (35-45%)

Small bowel (5-10%)

Retroperitoneal hematoma: 15%

slide20

Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE?

  • CT scan may confirm injury, but should not delay laparotomy in unstable patients.
  •  Twenty percent of patients with left lower rib fractures have associated splenic injury.
  •  Focused Assessment with Sonography for Trauma is useful if performed by experienced users.
  •  Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.
slide21

Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE?

  • CT scan may confirm injury, but should not delay laparotomy in unstable patients.
  •  Twenty percent of patients with left lower rib fractures have associated splenic injury.
  •  Focused Assessment with Sonography for Trauma is useful if performed by experienced users.
  •  Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.
seatbelt injuries
Seatbelt injuries

Unrestrained front and rear seat passengers are at unequivocally greater risk of intra-abdominal injury than their restrained counterparts.

The three-point shoulder-lap belt is the most effective restraining system and is associated with the lowest incidence of abdominal injuries.

However, abdominal injuries are still ascribed to shoulder-lap and lap-belt systems.

pathogensis
pathogensis
  • compression of bowel between the belt and the vertebral column.
  • an acute short closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures.
slide24

Clinically, two symptom patterns emerge.

  • ~1/4 of pt develop evidence of a hemoperitoneum secondary to mesenteric lacerations.
  • In the remainder, the intestinal injury most commonly involves the jejunum contusion or perforation.
  • Rare cases of acute abdominal aortic dissection with incomplete or complete occlusion have also been described, and injuries to the lumbar spine are not uncommon.
mechanism1
Mechanism
  • Stab wound
  • gunshot
slide27

Knives are not the sole implement used in stabbings.

  • Ice picks, pens, coat hangers, screwdrivers, and broken bottles.
  • most commonly in the upper quadrants, the left more commonly than the right.
stab wound
Stab wound
  • multiple in 20% of cases
  • involve the chest in up to 10% of cases.
  • Most stab wounds do not cause an intraperitoneal injury
  • the incidence varies with the direction of entry into the peritoneal cavity
  • The liver, followed by the small bowel, is the organ most often damaged by stab wounds.
gunshot wounds
Gunshot Wounds
  • handguns, rifles, and shotgun
  • the degree of injury depends .
  • amount of kinetic energy imparted by the bullet to the victim
  • mass of the bullet and the square of its velocity
  • Distance .
slide30

Missile velocities :

low (slower than 1100ft/sec)

medium (1100-2000ft/sec)

high (faster than 2000-2500ft/sec)

slide31

type I wounds: long range (>7 yards) , a penetration of subcutaneous tissue and deep fascia only.

  • Type II wounds: distance of 3 to 7 yards and may create a large number of perforated structures.
  • Type III wounds occur at point-blank range (<3 yards) and involve a massive destruction of tissue
slide32

multiple organ injuries are sustained, notably perforations to bowel .

  • greatest for small bowel, followed by the colon and then the liver.
missiles effects
Missiles effects
  • Extensive tissue damage
  • external contaminants tend to be dragged into the wound.
  • the closure of the tract immediately after the bullet's passage may lead to an underestimation of tissue damage.
  • high-velocity bullets can fragment internally
slide34

Small bowel injury is the most common injury resulting from ___ abdominal trauma.

  •  penetrating
  •  blunt
slide35

Small bowel injury is the most common injury resulting from ___ abdominal trauma.

  •  penetrating
  •  blunt
history
history
  • Primary goal is to identify that an injury exists, not necessarily making an accurate diagnosis.
  • The patient's history may be unobtainable, elusive, or temporarily abandoned while resuscitative measures are carried out.
  • History from prehospital care team or transferring hospital : the vital signs, physical assessment, prehospital course, and response to therapy should be obtained
  • Mechanism of injury is an important factor in developing a high index of suspicion; thus a detailed history is helpful if available.
slide38

Details about accident

  • Damage to car
  • Velocity
  • Steering wheel damage
  • Type of seatbelts used
  • Air bags deployed
  • All patients involved in deceleration injuries and bicycle injuries should be suspected of having intraabdominal injury
slide39

In penetrating trauma:

  • # of shots or stabs
  • Type of weapon
  • Distance b/w firearm and victim
examination
examination
  • Overall, the accuracy of the physical examination in patients with blunt abdominal trauma is 55% to 65%.
  • Although the presence of physical findings makes intraperitoneal injury more likely, their absence does not preclude serious pathology, and none is exclusively diagnostic of a specific injury.
slide41

Hypotension in the acute stage results from hemorrhage that is most often from a solid visceral or vascular injury.

  • hypotension with significant multiple blunt trauma and is unexplained, one should assume the presence of intraperitoneal hemorrhage until it is excluded.
slide42

In conscious, alert pt, look for:

  • Abdo tenderness,90%
  • Peritoneal irritation
  • Penetrating: wounds (log roll pt)
  • Ecchymosis, Cullen and Gray-Turner signs
slide43
Rectal exam is important; assess for blood and palpable bony fragments and position of the prostate. High riding prostate suggests posterior urethral tears.
  • Urethral disruption should be considered when blood is noted at the meatus.
  • Vaginal exam for bleeding – may suggest bony fragments causing laceration. Implications of bleeding during pregnancy should be considered.
slide44

The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT:

  •  abdominal pain and tenderness
  •  early bacterial peritonitis
  •  development of rebound, guarding and rigidity
  •  hypotension and tachycardia
  •  palpable mass and radiographic mass effect (may result from confined hemorrhage)
slide45

The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT:

  •  abdominal pain and tenderness
  •  early bacterial peritonitis
  •  development of rebound, guarding and rigidity
  •  hypotension and tachycardia
  •  palpable mass and radiographic mass effect (may result from confined hemorrhage)
diagnostic strategies
DIAGNOSTIC STRATEGIES
  • Hct: can be a delayed sign, should do serial.
  • WBC:  in stress, peritoneal irritation
  • Pancreatic enzymes: if normal, does NOT r/o pancreatic injury

 amylase: EtOH, narcotics

amylase & lipase: ischemia 2 hypotension

both non-specific & non-sensitive for pancreatic injuries

slide47

Are abdo x-rays useful in trauma?

Although plain abdominal films can demonstrate numerous findings, their place in acute trauma is limited. Because of spinal precautions, hemodynamic instability, time consuming or patient discomfort.

slide49

Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT :

  •  pleural effusion 
  •  appearance of the nasogastric tube in the chest 
  •  appearance of bowel loops in the chest 
  •  elevation of the diaphragm
  •  blurring of the diaphragm 
slide50

Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT :

  •  pleural effusion 
  •  appearance of the nasogastric tube in the chest 
  •  appearance of bowel loops in the chest 
  •  elevation of the diaphragm
  •  blurring of the diaphragm 
imaging
CT

Able to define organ injury

Good for retroperitoneal & vertebral column

Non-invasive

Not Operator dependant

Not great for hollow viscus

Stable patient

Cost $$$

Complications: IV or oral contrast

US

Good for solid organs

Portable

Fast

100 cc detection blood

Mediastinum evaluation

No radiation

No contrast need

Not see well: solid parenchymal, retroperitoneal, diaphragm

Problem if: obesity, gas

Less sensitive than DPL for hemoperitoneal

Operator dependant

Imaging
slide52

20 y/o female patient involved in a low velocity MVA. Upon initial exam no abnormalities noted, no complains.

The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT Scan which showed Liver Laceration Grade III. This patient was treated non-operatively.

preferred site of diagnostic peritoneal lavage
Preferred Site of Diagnostic Peritoneal Lavage
  • Standard adult :Infraumbilical midline C or SO
  • Standard pediatric: Infraumbilical midline C or SO
  • 2ed &3ed trimester pregnancy :Suprauterine FO
  • Midline scarring :Left lower quadrant FO
  • Pelvic fracture: Supraumbilical FO
slide58

List causes false negative DPL?

Catheter preperitoneal space

Fluid in compartment 2 adhesions

Diaphragmatic tear, so fluid goes into thoracic cavity

slide59

-sole absolute contraindication to DPL is the established need for laparotomy.

Relative contraindications:

  • prior abdominal surgery
  • Infections
  • Coagulopathy
  • obesity
  • second- or third-trimester pregnancy.
slide60

CLINICAL APPROCHES TO PT WITH:

  • BLUNT ABDOMINAL TRAUMA
  • STAB WOUND
  • GUNSHOT
  • ABDOMINAL WITH PELVIC TRAUMA.
approach to abdominal stab wound
Approach to abdominal stab wound.
  • Step I: Clinical Indications for Laparotomy.
  • Step II: Peritoneal Violation.
  • Step III: Injury Requiring Laparotomy.
peritoneal violation
Peritoneal Violation.
  • 1.   Evisceration
  • 2.    Intraperitoneal air
  • 3.    Local wound exploration
  • 4.    Ultrasonography
  • 5.    Laparoscopy
slide67

Stab wound to right lower quadrant with caecal evisceration.  No colon injury at laparotomy.

slide68

Eviscerated omentum is easily mistaken for subcutaneous fat, so care must be taken in the examination of open abdominal injuries. Which of the following statements regarding abdominal evisceration treatment is FALSE?

  •  Cover eviscerated organs with moist gauze or petrolatum gauze (to prevent desiccation) for replacement at laparotomy.
  •  Return all eviscerated organs to the peritoneal cavity. 
  •  Only organs with vascular compromise should be promptly returned to the abdominal cavity.
slide69

Eviscerated omentum is easily mistaken for subcutaneous fat, so care must be taken in the examination of open abdominal injuries. Which of the following statements regarding abdominal evisceration treatment is FALSE?

  •  Cover eviscerated organs with moist gauze or petrolatum gauze (to prevent desiccation) for replacement at laparotomy.
  •  Return all eviscerated organs to the peritoneal cavity. 
  •  Only organs with vascular compromise should be promptly returned to the abdominal cavity.
slide70

In the abdominal stab wound victim without clear indications for exploration (obvious peritoneal penetration, unexplained hypotension, or signs of peritoneal irritation), local wound exploration with local anesthesia should be performed; laparotomy should be performed if the __ is penetrated.

  •  rectus abdominis muscle 
  •  posterior rectus sheath 
  •  transversalis fascia.
slide71

25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar entered at the level of the epigastrium and exited through the left posterior thoracic wall.

Abdominal stab wound, with hepatic lesion grade II.

implements in situ
Implements in situ
  • implements in situ of the torso in the operating room.
  • to ensure expeditious control of hemorrhage
  • the implement reside within a vascular space or highly vascularized organ.
  • exceptions to this practice exist:
  • situations in which emergency department resuscitation is impeded by the presence of the implement
  • the patient is at high risk of significant morbidity from nontherapeutic laparotomy because of severe comorbid conditions or pregnancy.
conculsion
conculsion
  • The accuracy of physical examination is limited in cases of blunt and penetrating trauma. It is less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, mental retardation), and spinal cord injury.
  • The choice of diagnostic studies for abdominal trauma is based on clinical need first and foremost, as well as study availability and the trustworthiness of that study in a respective center
slide76

Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of hemoperitoneum in the critically ill blunt or penetrating trauma patient.

  • Clinical indications for laparotomy are more dependable in and more frequently applicable to cases of penetrating trauma than cases of blunt trauma.