questions 7

Abdominal Trauma

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Topic updated on 06/14/17 11:22am

Snapshot
  • A 30-year-old male victim of an automotive hit-and-run incident presents to the ED. Initial primary survey reveals no airway obstruction and good ventilation. Two large bore IV's are inserted and blood pressure is 95/60 mmHg, pulse is 95/min, respirations are 18/min, and SaO2 is 95% on room air. One liter of Lactated Ringer's is started. Secondary survey reveals no obvious source of blood loss. Despite this and fluid resuscitation, the patient's blood pressure drops to 85/55 mmHg. A FAST ultrasound exam reveals fluid surrounding the spleen and in Morrison's pouch. The patient is rushed to the OR for an exploratory laparotomy.
Introduction
  • Mechanisms of abdominal trauma include blunt and penetrating
    • blunt trauma accounts for 2/3 of all intraabdominal injuries 
      • motor vehicle crash (MVC) is main mode of injury
      • usually causes solid organ injury, but hollow viscus is also usually damaged
        • spleen is most common, liver is second
    • penetrating trauma accounts for 1/3
      • firearms, knives, and other impalers are main modes
      • usually causes hollow organ injury
        • if solid, liver is most common
Presentation
  • Mechanism of injury can create wide spectrum of presentations
    • symptoms and signs of blood loss may not be evident
    • therefore, mechanism of injury can solely determine need for further imaging workup
      • unprotected trauma
        • pedestrian victims of MVC, motorcycle / bicycle crash, assaults with objects
      • high-energy trauma
        • MVC with no restraints, known high speeds, death at scene, substantial vehicular damage
        • falls greater than 15 feet
      • minor trauma in patients with limited reserve to tolerate injury
        • elderly, patients with chronic debilitating disease, immunosuppressed
    • e.g., seatbelt-associated injuries are widespread
      • retroperitoneal duodenal trauma
      • intraperitoneal bowel transection
      • mesenteric injury
      • lumbar spine injury
    • penetrating trauma carries high risk of GI perforation and sepsis

Evaluation

  • Primary and secondary survey
    • physical exam is often unreliable, necessitating serial exams
      • abdomen
        • inspect for contusions, abrasions, seatbelt sign, distention
        • auscultate for bruits, bowel sounds
        • palpate for tenderness, rebound, rigidity, guarding
        • referred pain to shoulder 
        • DRE: rectal tone, blood, bone fragments, prostate location
      • placement of NG tube and Foley catheter
        • NG tube for decompression of stomach and proximal small bowel
          • contraindicated in patients with facial / basal skull fracture
        • Foley catheter for voiding in unconscious patient or patient with multiple injuries who cannot void spontaneously
          • contraindicated if blood at meatus, scrotum is ecchymotic, or prostate is high-riding on DRE
      • remember to assess other systems
  • Imaging
    • FAST ultrasound
      • identifies presence or absence of free fluid in peritoneal, pleural, pericardial cavities rapidly (< 5 minutes)
      • NOT used to identify specific organ injuries
      • if patient has ascites, FAST will be a false positive
    • diagnostic peritoneal lavage (DPL) 
      • rarely used (takes 1 hour)
      • most sensitive test for intraperitoneal blood
        • if > 10 ml gross blood, WBC > 500, amylase > 175, and/or bile/bacterial/foreign material found, DPL is considered positive
      • NOT for retroperitoneal bleed or diaphragmatic rupture
    • CT scan  
      • most specific test
      • significant radiation exposure
      • NOT used if patient is hemodynamically unstable
    • Radiograph
      • can detect free air under diaphragm, hernia, air-fluid levels, fractures
 Management
  • When to obtain imaging in blunt abdominal trauma
    • equivocal abdominal physical exam
    • multiple trauma patient with altered mental status 2/2 head trauma or drugs/alcohol
    • patient with suspected spinal cord injury causing abdominal anesthesia
    • unexplained shock/hypotension
    • fractures of lower ribs, pelvis, spine
  • What imaging to obtain in blunt abdominal trauma
    • start with FAST
      • if positive:
        • hemodynamically (HD) unstable:
          • start IV fluids 
          • go to OR for laparotomy 
        • HD stable: get CT (sometimes CT may be a better initial step depending on the context)
      • if negative:
        • HD unstable: repeat FAST or get DPL
        • but mechanism of injury is significant: get CT
        • if no risk factors: observe with repeat serial physical exams
      • if equivocal:
        • HD unstable: get DPL
        • HD stable: get CT
  • Solid organ injuries in blunt abdominal trauma
    • treat based on hemodynamic stability, not specific injury
      • if unstable, go to OR for laparotomy
      • if stable, spleen/liver/kidney lacerations and hematomas can be graded
        • higher grade portends increased risk of bleeding
          • consider angiography with embolization
  • Hollow viscus injuries in blunt abdominal trauma
    • evidence of perforation (free air in peritoneal cavity)
      • next best step: go to OR for laparotomy
  • Penetrating abdominal trauma
    • if gunshot wound
      • next best step: go to OR for laparotomy
        • any gunshot wound below the nipple line is considered to be abdominal
    • if shock, peritonitis, evisceration, free air in abdomen, or blood in NG/Foley/DRE
      • nest best step: go to OR for laparotomy
  • Retroperitoneal trauma
    • classified and triaged by zones on imaging
      • zone 1 (central)
        • high risk of bleeding from major vessels, pancreas, and duodenum
        • next best step: go to OR for laparotomy
      • zone 2 (perirenal)
        • if stable, next best step: continue to observe
        • if HD unstable or penetrating trauma, first obtain contralateral renal function
          • next best step: go to OR for exploration based on renal function
      • zone 3 (pelvic)
        • first control bleeding with pelvic binder
        • if stable and blunt trauma, no surgical exploration
          • next best step: consider angiography and embolization
        • if unstable and penetrating trauma, surgical exploration may be necessary
Complications
  • Surgical wound infection
    • manage with surgical debridement and broad-spectrum antibiotics 

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Qbank (2 Questions)

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(M2.GI.4752) A 34-year-old male is brought to the emergency department by fire and rescue after being involved in a motor vehicle accident. Paramedics report that the patient was driving the car and crashed into a tree. There were no passengers, and he was awake but disoriented at the scene. His temperature is 97.9°F (36.6°C), blood pressure is 131/88 mmHg, pulse is 89/min, respirations are 14/min, and SpO2 is 96% on room air. He is mumbling incoherent words and opens his eyes to voice. He has multiple lacerations on his face and arms. His cardiac exam is normal, and his lungs are clear to auscultation bilaterally. He withdraws to physical exam of the abdomen, and he is moving all extremities spontaneously. His blood alcohol level is above the legal driving limit. His head CT is shown in Figure A.

What is the best next step in management? Topic Review Topic
FIGURES: A          

1. Chest radiograph
2. Focused Abdominal Sonography for Trauma (FAST) exam
3. Abdominal CT
4. Diagnostic peritoneal lavage
5. Diagnostic laparoscopy

PREFERRED RESPONSE ▶
TAG
(M2.GI.4752) A 52-year-old woman is brought to the emergency department by fire and rescue after being involved in a motor vehicle accident. The paramedics report that the patient’s car slipped off the road during a rainstorm and rolled into a ditch. The patient was restrained and the airbags deployed during the crash. The patient has a past medical history of hypertension, hyperlipidemia, hypothyroidism, and gout. Her home medications include hydrochlorothiazide, simvastatin, levothyroxine, and allopurinol. The patient is alert on the examination table. Her temperature is 98.2°F (36.8°C), blood pressure is 83/62 mmHg, pulse is 131/min, respirations are 14/min, and SpO2 is 96%. She has equal breath sounds in all fields bilaterally. Her skin is cool with diffuse bruising over her abdomen and superficial lacerations, and her abdomen is diffusely tender to palpation. She is moving all four extremities equally, and her head CT shows no acute abnormalities. The patient’s FAST exam is equivocal.

Which of the following is the best next step? Topic Review Topic

1. Chest radiograph
2. Abdominal CT
3. Diagnostic peritoneal lavage
4. Diagnostic laparoscopy
5. Emergency laparotomy

PREFERRED RESPONSE ▶
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