Case-Based Abdominal Trauma

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Case-Based Abdominal Trauma

• Dr. Maggio and Ellen Morrow

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1st case

• The patient is a 24-year-old female
• rollover motor vehicle accident with GCS
  approximately 6 to 8 on scene.
• Her car rolled down a cliff, alcohol was
  involved. The patient was the unrestrained driver
  and was ejected. She was unresponsive in the
  field.

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Trauma assessment

• 2/28 725 pm
• P 97 86/50 100
• FAST
• Unresponsive
• Exam scalp lac, facial abrasion and R orbital
  trauma, abdomen normal

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Blunt Abdominal Trauma

• CT Indications
• Spinal cord injury, GCS lt 9
• Significant abdominal pain or tenderness
• Gross hematuria
• Non-ramus pelvic fracture
• Significant chest trauma
• Unexplained tachycardia/hypotension (with normal
  ultrasound)
• Ultrasound Indications
• Hypotension

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CT Abd Pelvis
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Liver injuries

• May be most common (vs spleen) in blunt abd
  trauma
• 95 of grade 1-3 can be managed non-op
• If there is extravisation, consider angio or OR
• Mobilize and feed when no evidence of bleed, no
  contact sports x 3 months post-injury

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CT criteria for staging liver trauma

• Grade 1 - Subcapsular hematoma less than 1 cm in
  maximal thickness, capsular avulsion, superficial
  parenchymal laceration less than 1 cm deep, and
  isolated periportal blood tracking
• Grade 2 - Parenchymal laceration 1-3 cm deep and
  parenchymal/subcapsular hematomas 1-3 cm thick
• Grade 3 - Parenchymal laceration more than 3 cm
  deep and parenchymal or subcapsular hematoma more
  than 3 cm in diameter
• Grade 4 - Parenchymal/subcapsular hematoma more
  than 10 cm in diameter, lobar destruction, or
  devascularization
• Grade 5 - Global destruction or devascularization
  of the liver
• Grade 6 - Hepatic avulsion

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Blunt Liver Injury Treatment

• Unstable patients mandatory laparotomy
• Stable patients selective nonoperative approach

Hepatic injury -Usually venous bleeding -Grade
I-III 94 success w/ nonop treatment -Grade
IV-V 20 amenable to nonop tx -HD stability,
stable Hct, observation -Complications delayed
hemorrhage, bile leak, biloma, intra/peri hepatic
abscess. -If stable with ongoing bleeding -
angiographic embolization
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Blunt Splenic Trauma Adult

• Consider early operative intervention in
  patients with severe brain injury, multisystem
  injuries, or medical comorbidities.
• There is risk of transfusion reactions, disease
  transmission and infectious morbidity with blood
  transfusion.
• At present, there are no studies establishing
  the safety of LMWH in patients with blunt splenic
  injury and this choice is at the discretion of
  the attending surgeon.
• Splenectomized patients should undergo
  meningococcal, pneumococcal, and Hib vaccines.
  The optimal timing is 14 days post-splenectomy.
  If there is legitimate concern about a patient
  not returning, vaccinate prior to discharge.
• At present, there are no studies evaluating the
  immunologic function of the embolized spleen or
  the need for vaccination after splenic
  angioembolization.

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Plain film findings for spleen lac

• The most common finding associated with splenic
  injury is left lower rib fracture. Rib fractures
  signify that adequate force has been transmitted
  to the LUQ to cause splenic pathology. Left lower
  rib fracture is present in 44 of patients with
  splenic rupture and necessitates further workup
  by abdominal CT.
• The classic triad indicative of acute splenic
  rupture (ie, left hemidiaphragm elevation, left
  lower lobe atelectasis, and pleural effusion) is
  not commonly present and should not be regarded
  as a reliable sign. However, any patient with
  apparent left hemidiaphragm elevation following
  blunt abdominal trauma should be considered to
  have splenic injury until proven otherwise.

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Grading spleen lacs

• Grade I
• Subcapsular hematoma of less than 10 of surface
  area
• Capsular tear of less than 1 cm in depth
• Grade II
• Subcapsular hematoma of 10-50 of surface area
• Intraparenchymal hematoma of less than 5 cm in
  diameter
• Laceration of 1-3 cm in depth and not involving
  trabecular vessels
• Grade III
• Subcapsular hematoma of greater than 50 of
  surface area or expanding and ruptured
  subcapsular or parenchymal hematoma
• Intraparenchymal hematoma of greater than 5 cm or
  expanding
• Laceration of greater than 3 cm in depth or
  involving trabecular vessels
• Grade IV - Laceration involving segmental or
  hilar vessels with devascularization of more than
  25 of the spleen
• Grade V - Shattered spleen or hilar vascular
  injury

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Blunt Abdominal Trauma

• SPLENIC INJURIES
• Often arterial hemorrhage, therefore nonoperative
  management less successful.
• Predictive factors for nonop success
• Localized trauma to flank/abdomen
• Agelt60
• No associated trauma precluding obs
• Transfusion lt4u prbcs
• Grade I-III
• Grade IV-V almost invariably require operative
  intervention
• Delayed hemorrhage (hours to weeks post-injury)
  8-21

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Renal Trauma

• Ten percent of patients with blunt abdominal
  trauma are found to have a urogenital injury.
• Renal parenchymal injuries are the most common.
  Of these injuries, 7590 may be classified as
  minor (Grade I-III) and require no intervention.
• Work up and treatment of the remaining major
  renal injuries has been controversial but there
  has been increasing interest in non-operative
  management because of associated decreased
  transfusion requirement, shorter ICU stay, and
  increased salvage rate of the kidney.
• CT scan of the abdomen/pelvis is the test of
  choice for staging renal injury.

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Evaluation

• Urine from the first post injury void should be
  evaluated on all patients with blunt abdominal
  trauma.
• Most patients with major renal trauma present
  with gross hematuria or hypotension, only 0.8
  1.2 of major renal injuries have neither.
• Microscopic hematuria (Greater than 5 RBC/HPF)
  Rarely associated with significant renal system
  injury. Patients require observation and repeat
  UA later in the ER or hospital to demonstrate
  resolution, in order to rule out other sources of
  hematuria such as malignancy.
• Children with significant microscopic hematuria
  (Greater than 50 RBC/HPF) should undergo
  abdominal/pelvic CT with Cystogram as their risk
  for significant renal injury is higher than in
  adults.
• Gross hematuria Patients require
  abdominal/pelvic CT with cystogram if
  hemodynamically stable. A retrograde urethrogram
  should be performed if there is blood at the
  meatus.
• Blunt vs. penetrating Blunt injury and stab
  wounds may be worked up in a similar fashion.
  Gunshot injuries often skip CT scan staging and
  require exploration because of hypotension,
  massive injury and delayed complications
  secondary to blast effect.

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Evaluation for Blunt Bowel or Mesenteric Injury
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2/29 120 AM A.V.

• Went to IR for splenic artery embolization, L
  hepatic artery embolization, coil embolization of
  R renal artery, IVC filter
• Received 3 units PRBC, HCT 28.6-gt36.4

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2nd case

• 18M presents to trauma bay with multiple stab
  wounds. He is awake and c/o pain. HR 115 but
  otherwise VSS. Stab wounds are 2cm in size,
  located below left costal margin, left flank, and
  left back.

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Truncal Stab Wounds

• The purpose of this algorithm is to guide the
  management of patients with stab wounds to the
  anterior abdomen, thoracoabdominal area, back,
  and flank.
• Anterior abdominal stab wounds are defined as
  those anterior to the mid-axillary line, from the
  xiphoid process to the pubic symphysis. Although
  optimal management of stable patients with AASW
  is debated, we have adopted a protocol of serial
  clinical assessments to determine the need for
  laparotomy. Retrospective review of RIH data
  suggests that this is a safe and effective
  approach in our institution.1
• Thoracoabdominal stab wounds are defined as those
  between a circumferential line connecting the
  nipples and tips of the scapulae superiorly, and
  the costal margins inferiorly. Occult
  diaphragmatic injury is problematic in this
  patient group.2 We have selected DPL as the
  preferred diagnostic modality to exclude
  diaphragmatic injury, with a RBC cutoff of
  5000/mm3 chosen to balance sensitivity and
  specificity.3
• Back/Flank stab wounds are defined as those
  between the tips of the scapulae and posterior
  iliac crests, posterior to the mid-axillary line.
  Physical examination alone is unreliable in this
  group, and DPL is unable to evaluate the
  retroperitoneum. Triple contrast (oral, rectal,
  and intravenous) CT has a sensitivity of 89-100
  and a specificity of 98-100 in diagnosing
  intra-abdominal and retroperitoneal injuries.4-7

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Penetrating Abdominal Trauma

• Stab Wounds Stratification by loci

Thoracoabdominal
Flank
Anterior Abdominal Explore locally, manage
expectantly with serial PE
Back
Peristernal Potential Mediastinal
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Penetrating Abdominal Trauma

• Stab Wounds Stratification by loci

Lower Chest
Flank explore locally triple contrast CT
Anterior Abdominal Explore locally, manage
expectantly with serial PE
Back
Peristernal Potential Mediastinal
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3rd case

• 60F pedestrian vs auto presents to trauma bay
• Primary survey airway clear, bilat BS, 1 radial
  pulses
• VS HR 105, BP 115/70

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3rd case

• Secondary survey PMH on coumadin for afib
• Abd mild TTP lower abdomen, FAST -, pelvis
  unstable.

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Pelvic fractures challenges

• Brisk bleeding with damage to surrounding
  vascular structures
• Secondary coagulopathy
• High rate of associated extrapelvic injuries
• Pelvic fxs hypotension mortality 36
• If laparotomy required, mortality 58
• Early mechanical stabilization and/or IR can help

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3rd case cont.

• The patient goes to the OR for emergent ex-fix
  b/c they were hemodynamically unstable in the
  trauma bay. They have not yet had an abdominal CT
  scan.

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3rd case cont.

• You decide to explore the abdomen.

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• You find a large billowing pelvic hematoma.

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Retroperitoneal hematomas

• Blunt explore all central (1) explore lateral or
  pelvic if expanding
• Penetrating explore all

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References

• Biffl, Trauma Handbook, RIH Dept of Surgery,
  Division of Trauma and Surgical Critical Care.
• Greenfield
• Cindy Kin Abdominal Trauma, SICU conference
  1/8/08
• Emedicine liver and spleen trauma.