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Assessment of Abdominal Trauma in the Emergency Department

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Title: Assessment of Abdominal Trauma in the Emergency Department


1
Assessment of Abdominal Trauma in the Emergency
Department
  • Debbie Washke, MD
  • Department of Emergency Medicine
  • Loma Linda University Medical Center
  • Month Year

2
Injury and Abdominal Trauma
  • Globally, traumatic injury accounts for 10 of
    all deaths
  • Trauma is now listed as the leading cause of
    death in persons between the age of 1-44
  • Peak incidence 14-30 years
  • One in ten deaths in trauma are due to abdominal
    injuries

3
Mechanism in Blunt Abdominal Trauma ( BAT )
  • Compression
  • Direct blow or compression against a fixed object
  • Commonly cause tears and subcapsular hematomas to
    solid viscera
  • Less commonly, transiently increase intraluminal
    pressure and lead to rupture
  • Deceleration
  • Stretching and linear shearing between a fixed
    and free object
  • Hepatic tears along the ligamentum teres, intimal
    injuries, mesenteric tears

4
Blunt Abdominal Trauma in the ED
  • Role of the emergency physician
  • Initial assessment
  • Mechanism
  • Difficult to make diagnosis
  • Resuscitation
  • Disposition
  • Indications for the OR
  • Study Choices
  • FAST
  • CT
  • DPL

5
Initial Assessment
  • Initially, Evaluation and Resuscitation occur
    simultaneously
  • Detailed History may be impossible
  • AMPLE
  • Allergies
  • Medications
  • Past medical history
  • Last intake
  • Events leading to presentation

6
Initial Assessment Description of mechanism
  • Predicts injury patterns and helps avoid pitfalls
  • Type of collision (frontal, lateral, sideswipe,
    rear, rollover) and speed
  • Damage to vehicle and whether prolonged
    extrication was required
  • Ejection from vehicle and/or co occupant death
  • Types of restraints
  • The presence of alcohol or drug use

7
Initial Assessment History
  • AMPLE
  • Mechanism per bystanders, medics etc
  • Patients with out of hospital hypotension are at
    increased risk for significant intra abdominal
    injury even if normotensive on arrival to the
    ED

8
Initial Assessment Physical Exam
  • RESCUSITATION continues as PE is completed
  • Airway, with cervical spine precautions
  • Breathing
  • Circulation
  • Disability
  • Exposure
  • Keep entire patient in mind

9
PE The Secondary Survey
  • Initial exam of abdomen in blunt trauma is
    difficult and often unreliable
  • Powell et al reported that clinical eval alone
    has an accuracy rate of only 65 for detecting
    presence or absence of intraperitoneal blood
  • Most reliable signs and symptoms
  • Pain, tenderness, GI hemorrhage, evidence of
    peritoneal irritation
  • Extremely difficult to assess the abdomen in
    cases of neurological dysfunction
  • Head or spinal cord injury
  • Substance abuse

10
Assessing the Abdomen
  • Inspection, auscultation, percussion, palpation
  • Inspection abrasions, contusions, lacerations,
    seat-belt signs
  • Grey Turner, Kehr, Balance and Cullen
  • Auscultation careful exam advised by ATLS ( of
    controversial utility in setting of trauma)
  • Percussion Subtle signs of peritonitis tympany
    in gastric dilatation or free air, dullness in
    hemoperitoneum
  • Palpation elicit superficial, deep, or rebound
    tenderness involuntary guarding

11
Adjuncts to the Abdominal Exam
  • Evaluate for pelvic instability
  • Potential for urinary tract injury as well as
    pelvic or retroperitoneal hematoma
  • Perform rectal exam to identify potential injury
    or bleed (controversial utility)
  • NG tube for abdominal distention to decompress
    stomach
  • Foley catheter placement after assessment for GU
    injury

12
The Workup Laboratory Studies
  • Commonly recommended studies
  • Serum glucose
  • CBC
  • Serum chemistries
  • Serum amylase
  • Urinalysis
  • Coagulation studies
  • Blood type and match
  • Blood ethanol, urine drug screens and a urine
    pregnancy test

13
CBC
  • Normal Hgb and Hct do not rule out significant
    hemorrhage
  • Delayed drop in acute bleeds
  • Hemodynamic instability much more reliable in
    assessment of volume status and need for
    transfusion in setting of trauma
  • Use platelet transfusions to treat severe
    thrombocytopenia (lt50,000/ml) and ongoing
    hemorrhage
  • WBC count is nonspecific
  • There is increased release of neutrophils from
    the marrow with physiologic stress

14
Serum Chemistries
  • Recently the usefulness of routine chemistries
    has been questioned
  • Most trauma victims are lt 40 y/o, and less likely
    to take medications that alter electrolytes
  • Important to recognize that medical conditions
    due play a role in a small percentage of traumas
  • Rapid bedside blood-glucose should be obtained in
    all trauma patients with altered mental status

15
Liver Function Studies
  • LFTs may be useful but elevation may be
    secondary to other conditions
  • Alcohol abuse
  • Hepatic Steatosis
  • One study shows that ALT or AST gt 130 U
    corresponds with significant hepatic injury
  • Bilirubin levels not specific indicators of
    hepatic injury

16
Amylase measurement
  • Controversial in setting of blunt abdominal
    trauma
  • An initial amylase has been shown to be neither
    sensitive or specific for pancreatic injury
  • Howeveran abnormally elevated level 3-6 hours
    after initial trauma has greater accuracy

17
Urinalysis
  • Indications include
  • significant trauma to the abdomen and/or flank
  • gross hematuria,
  • significant deceleration mechanism
  • Gross hematuria indicates a workup that includes
    cystography and IVP or CT with contrast
  • Urine pregnancy in females of child bearing age

18
Coagulation profile
  • Cost effectiveness of routine PT and PTT is
    questionable
  • Obtain in patients with a history of
  • Blood dyscrasias
  • Synthetic problems
  • On anticoagulants

19
Blood Type, screen and crossmatch
  • Screen and type blood from all trauma patients
    with suspected blunt abdominal injury
  • Initial crossmatch on a minimum of 4 units
  • If clear evidence of abdominal injury
  • And/or hemodynamic instability
  • Until crossmatch blood available use O-negative
    or type specific blood
  • An indication for immediate transfusion is
    hemodynamic instability despite administration of
    2 L of fluid to adult patients

20
Diagnostic Adjuncts
  • Plain films
  • FAST ( focused abdominal sonography for trauma)
  • CT studies
  • DPL

21
Plain Radiographs
  • Generally of lower priority, limited value but
    can demonstrate important findings
  • CXR may aid in diagnosis of abdominal injuries
    such as ruptured hemidiaphragm, pneumoperitoneum,
    free air
  • Pelvic or chest x ray may demonstrate fractures
    of the T and L spines
  • Transverse fractures of vertebral bodies
    suggests a higher likelihood of blunt injury to
    the bowel

22
FAST (focused assessment with sonography for
trauma)
  • Used to evaluate for abdominal injury in blunt
    trauma since the 1970s
  • Bedside ultrasound is rapid, portable, and
    noninvasive
  • Interpreted as positive if fluid found in any of
    the 4 acoustic windows
  • An exam is indeterminate if any window cannot be
    adequately assessed

23
FAST
  • Assumes that all clinically significant abdominal
    injuries are associated with hemoperitoneum
  • In reality, detection of free fluid is based on
    other factors
  • Body habitus, injury location, presence of
    clotted blood, position of patient and amount of
    free fluid present
  • Minimum threshold for detecting free fluid
  • Remains a subject of interest
  • At lower end of spectrum studies have shown that
    30-70 ml is minimum requirement for detection by
    US
  • In reality, in the hands of most operators it is
    limited in detecting lt 250 ml of intraperitoneal
    fluid

24
The 4 acoustic windows
  • Pericardiac
  • Perihepatic
  • Perisplenic
  • Pelvic

25
FAST Accuracy
  • For identifying hemoperitoneum in blunt abdominal
    trauma
  • Sensitivity 76-90
  • Specificity 95-100
  • Sensitivity increases for clinically significant
    hemoperitoneum
  • Rozycki et al US the most sensitive and specific
    modality for the evaluation of the hypotensive
    patient with blunt abdominal trauma

26
FAST Strengths and Limitations
  • Strengths
  • Rapid ( 2 min )
  • Portable
  • Relatively inexpensive
  • Technically simple, easy to train ( studies show
    competence can be achieved after 30 studies
  • Can be performed serially
  • Limiations
  • Does not typically ID source of bleeding, or
    detect injuries that do not cause hemoperitoneum
  • Limited in detection of intraperitoneal fluid
    (lt250 mL)
  • Poor at detecting bowel and mesenteric damage
  • Difficult to assess retroperitoneum
  • Limited by body habitus in the obese

27
Diagnostic Peritoneal Lavage
  • 98 sensitive for intraperitoneal bleeding (
    ATLS)
  • Open or closed (Seldinger) usually
    infraumbilical
  • Supraumbilical in pregnancy and pelvic fracture
  • Free aspiration of blood, GI contents, or bile in
    hemodynamically unstable patient requires
    laparotomy

28
Performing DPL
  • Methods include open, semi open and closed
    procedures
  • More typical to perform an open procedure if
    there are relative contraindications

29
How FAST is it ??
  • DPL results are positive if there is free
    aspiration of blood or GI contents
  • Samples need to be sent to lab if there is no
    gross aspiration of above body fluids
  • Fluid is positive if NS ( drained by gravity) has
    lt 100,000 RBCs/mL, gt 500 WBCs/mL, elevated
    amylase content, bile, bacteria, vegetable matter
    or urine
  • Delayed decision making process if sample is sent
    to lab

30
DPL Advantages vs Disadvantages
  • Disadvantages
  • Invasive
  • Difficult to perform in some populations
    (relative contraindications)
  • Time consuming if no gross blood or GI contents
    ??
  • Lavage fluid may interfere with subsequent
    imaging
  • May lead to high non-therapeutic laparotomy rate
    ( Bain et al suggests numbers as high as 36)
  • Advantages
  • Answers question quickly if there is gt 10 mL of
    blood or GI contents
  • Reported to be more sensitive than either CT or
    US for detection of hollow viscus injuries ( Hoff
    et al )

31
The Role of DPL
  • DPL regarded by many authors as obsolete
  • FAST has replaced DPL as investigation of choice
    in the hemodynamically unstable patient
  • It retains a role as a second line investigation
    tool and an adjunct to FAST
  • If fluid is found, DPL can help figure out what
    it is and where it is coming from but cannot ID
    the exact source

32
The Abdomen and Pelvic CT
  • CT scan remains the criterion standard for the
    detection of solid organ injuries
  • CT scans unlike FAST examinations or DPL, have
    capacity to determine the source of hemorrhage
  • Provide excellent imaging of the pancreas,
    duodenum, and GU system and can quantitate the
    amount of blood present in the abdominal cavity

33
CT Strengths and Limitations
  • Strengths
  • Gold standard for solid organ injury
  • Can determine source of bleeding
  • Detects retroperitoneal injuries that may not be
    identified by FAST or DPL
  • Reveals associated injuries ( bone and pelvic
    fractures
  • Limitations
  • Time consuming and typically involve leaving the
    department
  • In the unstable patient Death begins with a CT
  • Marginal sensitivity for diagnosing diaphragmatic
    injuries, pancreatic and hollow viscus injuries
  • Relatively expensive
  • Require IV contrast, which may cause an adverse
    reaction

34
Does FAST replace CT?
  • Only at the extremes
  • Unstable patient, () FAST ? OR
  • Stable patient, low force injury, (-) FAST ?
    consider observing patient and doing serial FAST
    exams

35
EAST Algorithm Unstable
36
EAST Algorithm Stable
37
CT EAST trauma guidelines
  • EAST level I recommendations (2001)
  • CT is recommended for evaluation of
    hemodynamically stable patients with equivocal
    findings on physical exam, associated
    neurological injury, or multiple extra-abdominal
    injuries
  • CT is the diagnostic modality of choice for
    nonoperative mgmt of solid visceral injuries

38
Solid Organ Injuries
  • Spleen
  • Liver
  • Pancreas

39
Spleen Injury
  • Most commonly injured organ
  • 25 of blunt abdominal injuries
  • Signs and symptoms often subtle
  • Left lower rib fractures
  • Non operative management in hemodynamically
    stable patients
  • Immunologic function has promoted salvage of the
    spleen rather than splenectomy

40
Spleen Injury
  • Non-operative management attempted in 60-80
  • 85-94 successful
  • 2/3 will fail nonoperative mgmt within the first
    24 hours
  • Salvage rates decrease with injury severity
  • Injury grade is not predictive of who will fail
  • Approx 10 will worsen as outpatient

41
Hepatic Injury
  • Relatively fixed position
  • Suspect in right lower chest injuries, rib
    fractures 7-10
  • 2nd most common organ injured
  • 15-20 of blunt abdominal injuries
  • Driving and fighting ( not necessarily at the
    same time )
  • Responsible for 50 of deaths
  • Non-operative management in hemodynamically
    stable patients

42
Hepatic Injury
  • Grade of Injury does not necessarily predict non
    operative failures
  • Failure rates approximately 2
  • If stable with ongoing bleeding angiographic
    embolization

43
Pancreas Injury
  • Isolated injury to this organ is uncommon
  • More frequently associated with liver injury
  • Missed injuries do occur
  • Normal in up to 40 of patients
  • Mechanism most often crush and transection
  • Delayed serum amylase elevations are much more
    sensitive
  • Significant injury carries grave prognosis

44
Bowel and Mesenteric Injury
  • Occurs in 5 of abdominal trauma
  • Mechanisms of injury
  • Compression increasing the intraluminal
    pressure in the bowel or by compressing
    fluid-filled bowel against solid structures
  • Deceleration stretching and tearing of bowel
    loops at points of fixation
  • Difficult to diagnose
  • Seatbelt sign present in 21

45
Bowel Injuries
  • Most Common Sites of Injury
  • Jejunum, ileum gt colon, duodenum ( 2nd and 3rd
    portions )
  • Requires emergent operative management
  • Undiagnosed injuries lead to fatal peritonitis or
    hemorrhage
  • Atypical for peritonitis to be present early on

46
CT findings Bowel and Mesentery
  • Signs of injury on CT
  • Bowel Direct
  • Bowel wall disruption
  • Oral contrast extravasation (typically forego
    this in trauma scenarios)
  • Bowel Indirect
  • Free air
  • Focal bowel wall thickening, wall enhancement
  • Mesentery Direct
  • IV contrast extravasation
  • Mesentery Indirect
  • Diffuse bowel wall thickening, enhancement
  • Mesenteric hematoma

47
CT in Bowel and Mesentery Injury
  • CT is currently best imaging tool
  • DPL is more sensitive (for bowel injury) but
    invasive minimal role in mesentery injury
  • CT sensitivity
  • 94 for bowel injury
  • 96 for mesentery injury

48
Diaphragmatic Injury
  • Diaphragm rupture rarely occurs as an isolated
    injury
  • Pelvic fracture
  • Splenic rupture
  • Liver laceration
  • Thoracic aorta injury
  • Only 40-50 are diagnosed immediately

49
Diaphragm Rupture
  • Uncommon fewer than 5
  • 80-90 occur due to MVC
  • Mechanism
  • Left lateral impact 3x more likely than frontal
    impact
  • 80-90 occur on the left

50
Penetrating Trauma Historic Timeline
  • Before WWI managed expectantly
  • During WWII studies showed early laparotomy
    improved survival
  • By late 1950s laparotomy became standard
  • In 1960s Shaftan suggested selective mgmt of
    stab wounds after observing an increased rate of
    ex laps with no identifiable injuries

51
Penetrating Abdominal Injury
  • Implies either a GSW or stab wound has penetrated
    the abdominal cavity
  • GSWs associated with high incidence of injury
    and typically require laparotomy
  • Stab wounds associated with lower incidence and
    may be expectantly managed

52
Relevant Anatomy
  • Thoracoabdominal area Nipples to 12th rib,
    between anterior axillary lines
  • Abdomen Nipples to anus between anterior
    axillary lines
  • Flank Between ipsilateral anterior and posterior
    axillary lines
  • Back Below the tip of the scapula, between
    posterior axillary lines

53
Penetrating Abdominal Trauma in the ED
  • The role of the ED physician
  • Initial Assessment
  • Stabilization/resuscitation with expected
    transfer to operating room in the hemodynamically
    unstable patient
  • Identification of injuries in the hemodyamically
    stable patient

54
Penetrating Trauma 3 Categories
  • Presentation
  • Pulseless
  • Hemodynamically
  • Unstable
  • Hemodynamically Stable
  • Injury Type
  • Major Vascular Injury
  • Vascular and/or solid organ injury and/or
    hemorrhage from other sites
  • Hollow viscus injury, vs renal or pancreatic
    injury

55
The Pulseless Patient
  • The pulseless patient with witnessed signs of
    life within 5 minutes prior to arrival
  • Need immediate laparotomy in the OR
  • ED thoracotomy is an option if no OR is available
  • A surgeon must be available if you are preparing
    to open the chest cavity and cross clamp the
    aorta
  • This procedure has a very low functional survivor
    yield

56
The Hemodynamically Unstable Patient
  • These patients must be taken to the OR
  • Includes non responders and transient responders
    to initial fluid bolus
  • No further investigations should be undertaken if
    the patient is unstable
  • For questions regarding whether abdomen is source
    or site of bleed
  • FAST, DPL can be undertaken

57
Penetrating Abdominal Injuries in the Unstable
Patient
  • Decision to perform laparotomy may be complicated
    by
  • Multiple gunshot/stab wound to more than 1 cavity
  • The wounds are at or cross junctional zones such
    as the costal margin
  • There is evidence of the possibility of cardiac
    tamponade

58
The Hemodynamically Stable Patient
  • Patients with clinical signs of peritonitis or
    with evisceration of bowel should be taken
    immediately to the OR
  • The goal in the stable patient with penetrating
    wounds
  • Identify injuries
  • Avoid unnecessary laparotomy

59
Adjuncts to Identifying Injury
  • CXR
  • May ID subdiaphragmatic air signals peritoneal
    penetration and warrants further investigation
  • Nasogastric Tube
  • Blood drained from the stomach will identify
    gastric injury
  • Urinary Catheter
  • Macroscopic hematuria indicates a bladder or
    renal injury
  • Rectal Examination
  • Rectal blood indicates a rectal or sigmoid
    penetration

60
Options for Management
  • Serial Physical Examinations
  • Local Wound Exploration
  • Diagnostic Peritoneal Lavage
  • Ultrasound ( FAST)
  • CT
  • Laparoscopy
  • Laparotomy

61
Serial Physical Examinations
  • Best sensitivity and negative predictive value of
    all modalities for penetrating abdominal trauma
  • Requires an awake, cooperative patient
  • Inpatient admission for frequent serial exams and
    hemodynamic monitoring
  • Unstable vitals, developing peritonitis to OR
  • If patient does well for 24 hours and tolerates
    po safe to discharge

62
Local Wound Exploration
  • Sensitivity and Specificity 71 and 77
  • Wound is extended under local anesthesia and
    tracked through tissue layers
  • Can be done in OR or ED
  • Invasive with rare complications
  • Penetration of the anterior fascia is considered
    a LWE
  • LWE leads to laparotomy or other studies
  • May lead to high non therapeutic lap rate

63
Diagnostic Peritoneal Lavage
  • Sensitivity is 87-100, specificity is 52-89
  • Role of DPL in stable patient differs from that
    in the unstable patient
  • Role in stable patient with penetrating injury is
    to ID hollow viscus or diaphragmatic injury
  • Fecal or food matter seen on microscopy is
    diagnostic but this is rare
  • Disadvantages DPL is invasive, does not evaluate
    the retroperitoneum and has a high false positive
    rate

64
FAST
  • Role of FAST in penetrating trauma has not been
    fully evaluated
  • Ultrasound as yet cannot detect the small amounts
    of fluid associated with hollow viscus injury
  • A positive FAST indicates peritoneal penetration
    but does not discriminate between injuries
    requiring intervention
  • A negative FAST does not exclude signficant
    injury

65
CT Scan
  • Most studies recommend a multislice scanner with
    triple contrast protocol
  • IV, oral and rectal
  • CT gives best assessment of retroperitoneal
    structures

66
Laparoscopy
  • Technology still in infancy and is user dependent
  • In most studies, laparoscopy has a significant
    false negative, primarily due to missed bowel
    injuries
  • Limited in evaluating for retroperitoneal
    injuries
  • It is the diagnostic method of choice for
    suspected diaphragmatic injuries

67
Laparotomy
  • Still has a role in resource limited environments
    and occasionally in cases of multi-cavitary
    injuries
  • In most cases the non therapeutic lap rate will
    be unacceptably high
  • A negative lap has complications of 12-40 with
    hospital stays of 4-9 days
  • Difficult to advocate when CT or serial physical
    exams has such a low missed injury rate

68
Special Situations Thoracoabdominal Junction
  • Wounds to thoracoabdominal junction
  • Need to be evaluated for diaphragmatic injury
  • Particularly in multi-trauma, such as associated
    PTX, liver injury
  • Options are MRI, CT, US or laparoscopy
  • Laparoscopy is the study of choice

69
Special Situations Flank or Back Wounds
  • Flank or Back Wounds
  • Associated with retroperitoneal injuries
    including the colon, kidney and lumbar vessels
  • Pancreas, aorta and inferior vena cava are less
    likely to be injured but must be considered
  • Injury to the colon is the most frequently missed
  • Serial PEs should be extended to 72 hours if
    colon injury is suspected

70
Special Situations Wound to Buttock or Perineum
  • Buttock / Perineum wounds
  • Most dangerous occult injury in this area is to
    the rectum
  • Any penetrating injury to the gluteal region
    carries this risk
  • DRE is inadequate and full proctoscopy and
    sigmoidoscopy should be performed

71
Case 1
  • 24 y/o female
  • Rollover MVA with GCS of approximately 6-8 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

72
Trauma Assessment
  • P 97 BP 86/50 O2 sats 92
  • Unresponsive
  • Primary Survey
  • Management ?
  • Secondary Survey
  • No abdominal distention, BS present
  • CXR, FAST done during secondary survey
  • Pulmonary contusions, rib fractures on left 10-12
  • FAST negative

73
Management
  • Trauma activation
  • Secure airway, c-spine immobilization
  • 2 large bore IVs with 2 L of fluid
  • Exposure to evaluate completely
  • Secondary exam
  • How reliable is abdominal exam ?
  • Hemacue is 11, BG is 130
  • CXR
  • FAST

74
Management
  • Patient received 2 liters of NS with
    stabilization of BP
  • VSS HR 86 BP 100/60 O2 sats 100 on
    ventilator
  • FAST is repeated --

75
Second FAST
76
CT or OR ?
  • Should patient go to OR or CT ?
  • Vitals have stabilized
  • Hemacue has dropped to 9.0 and a unit of PRBCs
    has been started

77
CT scan
78
Case 2
  • 18 y/o male presents to ED with multiple stab
    wounds. He is awake and c/o pain at wound sites.
    Stab wounds are 2 cm in size, located below the
    left costal margin, left flank and left back
  • VS HR 120 BP 130/76 O2 sats 96

79
Assessment and Management
  • Level B trauma activation
  • Establish 2 large bore IV lines
  • Primary Survey
  • ABCDE, no heavy bleeding from wounds
  • Secondary Survey
  • Oozing at site of all three stab wounds, abdomen
    tender primarily near wound sites, no rebound or
    signs of peritonitis
  • CXR
  • EFAST
  • Hemacue
  • Pain Control

80
Management
  • How would you manage this patient ?

81
Case 3
  • 60 y/o female pedestrian vs auto presents to ED
  • Medical history of hypertension, atrial
    fibrillation and CHF
  • Patient alert and oriented, no LOC at scene
  • VS HR 105 BP 115/70 O2 sats 96

82
Management
  • Level A trauma activation
  • Primary Survey what needs to be done ?
  • Secondary Survey
  • Diffuse tenderness to lower abdomen
  • for pelvic instability
  • FAST negative
  • CXR negative , would you like additional studies
    ?
  • Hemacue is 10.8

83
Management
  • Do you need labs ?
  • What other concerns do you have
  • INR is 7.4
  • VS are now HR 117 BP 100/50
  • What would you like to do ?
  • Repeat FAST shows a pelvic hematoma ??? Your just
    that good ?
  • What is the patients disposition ?

84
Thank You
85
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