Transcript Evaluation of Abdominal Trauma

Principles of Surgery
Evaluation of
Abdominal Trauma
Anand Pandya MD FRCSC
Trauma Surgery and Critical Care Medicine
Clinical Associate
St. Michael’s Hospital, University of Toronto
Objectives

Evaluation of Abdominal Trauma
Mechanisms of Injury
 Assessment of Unstable Patients
 Assessment of Stable Patients
 Case Discussions

Diagnostic tests
 Decision making

External Anatomy of Abdomen
Mechanism of Injury: Blunt

Compression, crush, or sheer
injury to abdominal viscera:
deformation of solid or hollow
organs, rupture (e.g. small bowel,
gravid uterus)

Deceleration injuries: differential
movements of fixed and nonfixed structures (e.g. liver and
spleen laceration at sites of
supporting ligaments)
Pattern of Injury in Blunt Abdominal Trauma
Spleen
40.6%
Colorectal
3.5%
Liver
18.9%
Diaphragm
3.1%
Retroperitoneum
9.3%
Pancreas
1.6%
Small Bowel
7.2%
Duodenum
1.4%
Kidneys
6.3%
Stomach
1.3%
Bladder
5.7%
Biliary Tract
1.1%
* Rosen: Emergency Medicine (1998)
Mechanism of Injury: Penetrating
● Stab
● Low energy, lacerations
● Gunshot
● Kinetic energy transfer
● Cavitation, tumble
● Fragments
Assessment: History



AMPLE
Mechanism
MVC:






Speed
Type of collision (frontal, lateral,
sideswipe, rear, rollover)
Vehicle intrusion into passenger
compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle
Assessment: Physical Exam

Inspection, auscultation, percussion,
palpation

Inspection: abrasions, contusions,
lacerations, deformity




Grey-Turner, Kehr, Balance, Cullen
Auscultation: careful exam advised by
ATLS. (Controversial utility in trauma
setting.)
Percussion: subtle signs of peritonitis;
tympany in gastric dilatation or free
air; dullness with hemoperitoneum
Palpation: elicit superficial, deep, or
rebound tenderness; involuntary
muscle guarding
Abdominal Injury
Factors that Compromise the Exam
● Alcohol and other drugs
● Injury to brain, spinal cord
● Injury to ribs, spine, pelvis
Caution
A missed abdominal
injury can cause a
preventable death.
Case 1






40 yo male, MVC – driver
GCS=7, Airway
100% on 15L face mask
BP=80/50, P=140
Diagnosis?
Management?
Decision Making



Airway
Breathing
Circulation
SHOCK
Hemodynamically
Stable
Transient
Responder
How are you going to assess?
Hemodynamically
Unstable
Shock



Scalp
Chest – clinically vs. chest x-ray
Abdomen
FAST
 DPL
 Pelvic X-ray



Extremities – Femur
Other causes of shock – cardiogenic,
obstructive, anaphylactic, septic
FAST
Focused Abdominal Sonography for Trauma
(FAST)

Demonstrate presence of free intraperitoneal fluid

Evaluate solid organ hematomas

Advantages



No risk from contrast media or radiation
Rapid results, portability, non-invasive, ability to repeat exams.
Disadvantages



Cannot assess hollow visceral perforation
Operator dependent
Retroperitoneal structures are not visualized
FAST

Four View Technique:




Morrison’s pouch (hepatorenal)
Douglas pouch (retropelvic)
Left upper quadrant (splenic view)
Epigastric (View pericardium)
Diagnostic Peritoneal Lavage


Introduced by Root (1965)
Indications for DPL in blunt trauma:
1.
Hypotension with evidence of abdominal injury
2.
Multiple injuries and unexplained shock
3.
Potential abdominal injury in patients who are unconscious,
intoxicated, or paraplegic
4.
Equivocal physical findings in patients who have sustained high-energy
forces to the torso
5.
Potential abdominal injury in patients who will undergo prolonged
general anesthesia for another injury, making continued reevaluation of
the abdomen impractical or impossible
Contraindications of DPL

Absolute :






Peritonitis
Injured diaphragm
Extraluminal air by x-ray
Significant intraabdominal injury by CT scan
Intraperitoneal perforation of the bladder by cystography
Relative :





Previous abdominal operations (because of adhesions)
Morbid obesity
Gravid Uterus
Advanced cirrhosis (because of portal hypertension and the risk of
bleeding)
Preexisting coagulopathy
DPL: Procedure
Evaluation of DPL

Fluid is sent for: cell count, amylase, alk phos, presence of bile
Aspirate
Lavage
Negative
Index
Positive value
Blood
>10 mL
Fluid
Enteric content
RBC
> 100,000/mL
WBC
> 500/mL
Amylase
>175 U/dL
Alk Phos
> 3 IU
Bile
Confirmed
RBC
< 50,000/mL
WBC
< 100/mL
Amylase
< 75 U/dL
Diagnostic Peritoneal Lavage
RBC Count
Incidence of visceral damage
>100,000
95%
20,000-100,000
15-25% Warrant further investigation
<20,000
< 5%

Complications of DPL: Perforation of small bowel, mesentery,
bladder and retroperitoneal vascular structures.

Limitation: offers no information about status of
retroperitoneal organs nor allow determination of which organ
has been injured.
Indications for Laparotomy – Blunt Trauma
● Hemodynamically abnormal with suspected
abdominal injury (DPL / FAST)
● Free air
● Diaphragmatic rupture
● Peritonitis
● Positive CT
On Route to OR




ABC
Chest x-ray, Pelvis x-ray
IV access
Resuscitation






What is the goal?
Group and Match
Notify OR, Surgeon, Anaesthesia
Request OR equipment
Consent
Antibiotics
Case 1: Learning Points




Recognize Shock
Hemodynamically unstable = OR
Role of FAST, DPL
Permissive hypotension in resuscitation until
bleeding controlled
Case 2:

40 yo male, MVC Driver
Airway
Breathing = 100% on 5L NP
Circulation = 130/70, P=100
Disability, GCS=14
Exposure

Management?





How do you investigate the
Abdomen?

Hemodynamically stable:
ABCDE, secondary survey
 FAST
 CT Scan
 Lab work

Imaging in Blunt Abdominal
Trauma – CT Scan

Sensitivity:

Solid organ injury: 97% [II,III]

Identify Contrast extravasation

Guide Operative vs. Non-operative management

Enteric injury: 64 – 94% [III]

Diaphragmatic injury: 61% [III]

Pancreatic injury: 30% [III]
CT Scan
CT Scan
CT Scan
Role of Laboratory Tests


Amylase
B-HCG
In Pregnancy


X-rays
Ultrasound
Abdominal
 Fetal



Circumferential Lead Shield
Caution with Radiation exposure
Decision Making



Stable patient
CT Scan
Operative





Solid organ injury, hypotensive
Hollow viscus organ injury
Intraperitoneal bladder injury
Diaphragmatic injury
Non-operative management


Observation
Interventional Radiology
Learning Points Case #2




CT scan is helpful for decision making in a
stable patient
Poor detection of hollow viscus, pancreatic and
diaphragmatic injury
Be worried of free fluid in abdomen
Repeat CT Scan and close clinical observation
Case #3







30 yo male
GSW to buttock
Airway
Breathing
Circulation
What injuries are you concerned about?
How are you going to investigate?
Transpelvic GSW

Rectal injury
Extraperitoneal – rigid sigmoidoscopy
 Intraperitoneal – CT scan with rectal contrast or
laparotomy


Bladder injury
Hematuria
 Cystogram


Urethral injury

Retrograde urethrogram
Transpelvic GSW

Vascular injury
FAST
 CT Scan


Pelvic fracture


X-ray
Female – Uterine injuries

CT Scan
Decision Making


Low threshold for laparotomy with GSW
Bowel injury = sigmoidoscopy
Intraperitoneal – repair/resect
 Extraperitoneal – diversion


Bladder injury = cystogram
Intraperitoneal – surgical repair
 Extraperitoneal – foley catheter

Learning Points Case #3




Think of associated injuries
GSW have blast effect, variable trajectory
Diagnostic tests guide treatment
Early laparotomy
Case #4

30 yo male
Stab wounds to abdomen
Airway
Breathing
Circulation

What is your management?




Options for Management
Diffuse Abdominal Tenderness
Yes
Laparotomy
No
Hemodynamic Stability?
Indications for Laparotomy – Penetrating Trauma
●
●
●
●
●
Hemodynamically abnormal
Peritonitis
Evisceration
Positive DPL, FAST, or CT
Violation of peritoneum
Options for Management

Hemodynamically stable penetrating injury
 Serial Observation
 Wound Exploration
 DPL
 CT scan +/- Contrast
 Laparoscopy
 Laparotomy
 Ultrasound/echo – cardiac box
 Pericardial window – cardiac box
Stab Wounds
Shorr RM, Gottlieb MM, et al. Selective management of abdominal stab wounds:
Importance of the physical examiantion. Arch Surg 1988, 123(9):1141-5.
330 patients over 12 months
154 (47%) acute abdomen, underwent immediate celiotomy
Even of these, 31% negative
176 (53%) observed
3 (1.7%) injuries required celiotomy (no adverse effects)
The Value of Serial Observation
Learning Points Case #4




Injury from stab wounds are different from
GSW
Indications for early surgery
Consider diagnostic options
Value of serial exam
Case #5




50 yo male, MVC driver
Airway
Breathing
Circulation


100/70, P=130
What is the next step?
Priorities


ABC
Consider associated injuries with pelvic trauma
Blood vessels – arterial and venous
 Bone
 Bladder and urethral
 Bowel
 Baby (Uterus)
 Other Body injuries

Vascular Anatomy
1. Abdominal Aorta
2. Common Iliac Artery
3. Internal Iliac
4. External Iliac
5. Superior Gluteal
6. Obturator Artery
AP Pelvic # with bladder injury
The Pelvic Mantra….
Unstable Fractures Lead to Unstable
Patients
- stability should be tested by GENTLE manipulation
- stability should only be performed ONCE
Minimize further hemmorage !
Young-Burgess Classification System
LC
VS
APC
Unstable
Decision Making

Hemodynamically Stable
CT Scan + cystogram
 If blush then observe vs. embolize


Hemodynamically unstable, Pelvis unstable
FAST or DPL to rule out intra-abdominal injury
 Bedsheet wrap pelvis, Ex-fix, C-clamp
 If intraperitoneal blood = laparotomy
 If no intraperitoneal blood = Angiogram

Angiography and Embolization
Initial Angiogram
Post-Embolization
Right iliac angiogram: acute extravasation (left) from the right superior and inferior
lateral sacral arteries. Post-embolization (right) showing no evidence of acute arterial
bleeding
Learning Points Case #5




Unstable vs. Stable patients
Recognize pelvic fracture
Rule out bladder injuries
Angiogram and emobolization of arterial injuries
Role of Interventional Radiology

Embolization
Spleen
 Liver
 Pelvis


Angioplasty + Stent


Renal artery dissection
Stent

Thoracic aortic injuries
Spleen Embolization
Renal Artery Dissection
Blunt Thoracic Aortic Injury
Summary





Mechanism of injury – Blunt vs. Penetrating
ABC  Stability of trauma patients
Select ppropriate diagnostic imaging
Think about associated injuries
Multi-modality





Clinical
FAST
CT Scan
Interventional Radiology
Surgical exploration
Questions