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ABDOMINAL TRAUMA

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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. – PowerPoint PPT presentation

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Title: ABDOMINAL TRAUMA


1
ABDOMINAL TRAUMA
  • Mark Boyko EM

2
Where to Start?
  1. Review key aspects of abdo trauma.
  2. Important imaging modalities.
  3. An Approach to Blunt abdo trauma.
  4. An Approach to Penetrating abdo trauma

3
Anatomy
  • The anterior abdomen is defined as that region
    between the anterior axillary lines from the
    anterior costal margins to the groin creases.

4
Abdominal Layers
Transversalis Fascia
Peritoneum
5
BLUNT TRAUMA
  • Most commonly MVAs
  • Also involves fall from height, assaults, sports
    injuries
  • Can injure solid organs (liver, spleen) or hollow
    viscus (bowel)

6
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

7
Question
  • TRUE OR FALSE In the setting of abdominal
    trauma, absent bowel sounds after 30 seconds of
    listening indicates bowel perforation

FALSE
8
Question
  • Which organ is most commonly injured in blunt
    abdominal trauma?
  • A) Liver
  • B) Spleen
  • C) Bowel
  • D) Pancreas
  • E) Bladder

9
Splenic Injury - Grading System
  • I - Hematoma, subcapsular lt10 SA
  • Capsular Lac lt1cm
  • II - Hematoma, subcapsular 10-50 SA
    intraparenchymal lt5cm
  • Capsular Lac 1-3cm
  • III - Hematoma, subcapsular gt50 SA
    intraparenchymal gt5cm
  • Capsular Lac gt3cm (or parenchymal depth)
  • IV - Hematoma ruptured into parenchyma
  • Hilar Injury devascularizing spleen gt25
  • V - Vascular hilar injury devascularing spleen
    100, or
  • Shattered

10
Splenic Injury - Grade 4
11
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) gt12 hrs

12
Question
  • TRUE or FALSE The seat belt sign is a strong
    indicator of serious abdominal injury

TRUE
13
The American Surgeon 1999 Feb65(2)181-5.
  • Prospective Study of 410 patients, restrained MVC
    occupants, 77 had seat belt sign. 23 with sign
    had serious intrabdominal injury vs 3 without.
  • Have a high index of suspicion!

14
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15
Physical Exam
  • BOTTOM LINE In the trauma patient, a normal
    physical exam of the abdomen doesnt equate to
    much. You NEED to do further testing.

16
Trauma Labs
  • Can you name the complete list of trauma labs
    ordered at FMC?
  • CBC, lytes, Cr, Glucose
  • EtOH
  • PT/INR
  • Type Screen
  • Urinalysis

17
Trauma Labs
  • WBC or Hct not particularly helpful in first few
    hours
  • Amylase/Lipase not helpful for pancreatic trauma
  • LFTs can indicate trauma, but gives no
    indication of the severity.
  • BOTTOM LINE Other than Hgb, your labs do not
    guide your clinical management

18
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

19
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

20
Question
  • FAST ultrasound is now called e-FAST what does
    the e stand for?

Extended Lung bases
21
FAST - Looking for Free Fluid
22
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
    200523543643

23
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

24
Diagnostic Peritoneal Taps
  • Question What is considered a positive
    peritoneal aspirate?

10 cc of frank blood
25
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.

26
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

27
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28
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29
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

30
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

31
Diagnostic Peritoneal Lavage
  • Step 2. DPL.
  • Hook up 1L of Ringers to the peritoneal
    catheter, and squeeze into the abdomen.
  • Once infused, put the empty Ringers bag on the
    floor, and let it back-fill via gravity
  • Send off 10cc for analysis, if 100,000 RBC/cc it
    is positive

32
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)

33
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 Feb17(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

34
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

35
CT Scan - Bowel Injury?
  • CT SENS for bowel injury gt90, 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

36
BLUNT ABDO TRAUMAAN APPROACH
  • The Unstable Patient
  • vs
  • The Stable Patient
  • its as easy as 1-2-3

37
The UNSTABLE Patient
  • STEP 1. Is there peritonitis? YES or NO.
  • YES goes to the OR.

38
The UNSTABLE Patient
  • STEP 2. Do a FAST.
  • If positive If negative
  • To the OR Look for another area of injury

39
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

40
The STABLE Patient
  • STEP 1. Can you evaluate them? (poor GCS,
    intoxication)
  • YES NO
  • Do Phx CT Scan

41
The STABLE Patient
  • STEP 2. Is there peritonitis?
  • YES NO
  • To the OR do a FAST

42
The STABLE Patient
  • STEP 3. Do a FAST.
  • If positive If negative
  • Get CT Scan Serial exam q12hrs

43
Injury Severity Scale0 -75
  • 6 areas of the body
  • Head Neck
  • Face
  • Chest
  • Abdomen
  • Extremity
  • External
  • 6 options for injury
  • Minor
  • Moderate
  • Serious
  • Severe
  • Critical
  • Unsurvivable

44
Example
Region Injury Injury Score Square Top Three
HeadNeck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion Liver Complex Rupture Spleen 2 5 25
Extremity Femur 3
External No Injury 0
Total ISS 50
45
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46
Revised Trauma ScoreRTS 0.9368 GCS 0.7326
SBP 0.2908 RR
GCS SYS BP RR Score
13-15 gt89 10-29 4
9-12 76-89 gt29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
47
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48
Take a breather
  • Guinness World Record - Longest Time Waiting for
    a Bed at a Hospital?

49
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.

50
PENETRATING Abdo Trauma
51
Question
  • Most commonly injured organ in penetrating
    trauma?
  • A) Liver
  • B) Spleen
  • C) Bowel
  • D) Kidney
  • E) Bladder

52
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

53
Stab Wounds - Non operative Management
  • No peritonitis,
  • No evisceration,
  • No hemodynamic instability
  • can be safely selected for non-operative care

54
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.

55
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

56
Question
  • TRUE or FALSE FAST ultrasound has a role in
    penetrating trauma.

TRUE
57
FAST in Penetrating Trauma
  • FAST is now being used for penetrating trauma.
  • A positive FAST has a positive predictive value
    of gt90 percent, but a negative FAST does not rule
    out peritoneal violation.
  • Sensitivity 60-90 in early studies

58
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,
    doesnt tell you which organ is affected
  • If normal CT --gt Observe / discharge

59
CT Scan
  • Stab or Gunshot - SENS 97, SPEC 98 with triple
    contrast, but a recent study shows only IV
    contrast approaches same numbers

60
An APPROACH - Penetrating Trauma
  • 2 BIG QUESTIONS
  • 1. Has the peritoneal lining been disrupted?
  • 2. If so, is there organ injury?

61
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?)

62
Diaphragmatic Rupture
63
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.

64
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.

65
An APPROACH
  • STEP 3. Is there an injury that requires
    operative repair?
  • CT Scan
  • Normal CT --gt Observe / discharge

66
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 -gt decision
    made on Phx and CT, majority of these d/c home
    without an operation.

67
So In Summary
  • BLUNT TRAUMA

UNSTABLE PATIENT!
68
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.

69
In Summary
  • BLUNT TRAUMA

STABLE PATIENT
70
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

71
In Summary
  • PENETRATING TRAUMA

UNSTABLE PATIENT!
72
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.

73
In Summary
  • PENETRATING TRAUMA

STABLE PATIENT
74
STABLE
  • Relax
  • 1. Has the peritoneal lining been disrupted? YES
    or NO
  • 2. If so, is there organ injury?
  • YES or NO

75
Ask Me For References
  • Questions??
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