Transcript Abdominal Trauma

Assessment of Abdominal
Trauma in the Emergency
Department
Debbie Washke, MD
Department of
Emergency Medicine
Loma Linda University
Medical Center
[Month] [Year]
Injury and Abdominal Trauma
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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 144
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Peak incidence 14-30 years
One in ten deaths in trauma are due to
abdominal injuries
Mechanism in Blunt Abdominal
Trauma ( BAT )
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Compression
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Direct blow or compression against a fixed object
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Commonly cause tears and subcapsular hematomas to solid
viscera
Less commonly, transiently increase intraluminal pressure
and lead to rupture
Deceleration
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Stretching and linear shearing between a fixed and
free object
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Hepatic tears along the ligamentum teres, intimal injuries,
mesenteric tears
Blunt Abdominal Trauma in the
ED
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Role of the emergency physician
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Initial assessment
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Mechanism
Difficult to make diagnosis
Resuscitation
Disposition
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Indications for the OR
Study Choices
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FAST
CT
DPL
Initial Assessment
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Initially, Evaluation and Resuscitation
occur simultaneously
Detailed History may be impossible

AMPLE
Allergies
 Medications
 Past medical history
 Last intake
 Events leading to presentation
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Initial Assessment: Description of
mechanism
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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
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Initial Assessment: History
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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
Initial Assessment: Physical Exam
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RESCUSITATION continues as PE is
completed
Airway, with cervical spine precautions
 Breathing
 Circulation
 Disability
 Exposure
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Keep entire patient in mind
PE: The Secondary Survey
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Initial exam of abdomen in blunt trauma is
difficult and often unreliable
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Most reliable signs and symptoms
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Powell et al reported that clinical eval alone has
an accuracy rate of only 65% for detecting
presence or absence of intraperitoneal blood
Pain, tenderness, GI hemorrhage, evidence of
peritoneal irritation
Extremely difficult to assess the abdomen in
cases of neurological dysfunction
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Head or spinal cord injury
Substance abuse
Assessing the Abdomen
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Inspection, auscultation, percussion, palpation
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Inspection: abrasions, contusions, lacerations, seatbelt signs
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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
Adjuncts to the Abdominal Exam
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Evaluate for pelvic instability
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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
The Workup: Laboratory Studies
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Commonly recommended studies
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Serum glucose
CBC
Serum chemistries
Serum amylase
Urinalysis
Coagulation studies
Blood type and match
Blood ethanol, urine drug screens and a urine
pregnancy test
CBC
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Normal Hgb and Hct do not rule out significant
hemorrhage
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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 (<50,000/ml) and ongoing
hemorrhage
WBC count is nonspecific
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There is increased release of neutrophils from the
marrow with physiologic stress
Serum Chemistries
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Recently the usefulness of routine
chemistries has been questioned
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Most trauma victims are < 40 y/o, and less
likely to take medications that alter
electrolytes
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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
Liver Function Studies
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LFT’s may be useful –but elevation may
be secondary to other conditions
Alcohol abuse
 Hepatic Steatosis
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One study shows that ALT or AST > 130 U
corresponds with significant hepatic
injury
Bilirubin levels: not specific indicators of
hepatic injury
Amylase measurement
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Controversial in setting of blunt
abdominal trauma
An initial amylase has been shown to be
neither sensitive or specific for
pancreatic injury
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However…an abnormally elevated level 3-6
hours after initial trauma has greater
accuracy
Urinalysis
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Indications include
significant trauma to the abdomen and/or flank
 gross hematuria,
significant deceleration mechanism
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Gross hematuria indicates a workup that
includes cystography and IVP or CT with
contrast
Urine pregnancy in females of child bearing age
Coagulation profile
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Cost effectiveness of routine PT and PTT
is questionable
Obtain in patients with a history of
Blood dyscrasias
 Synthetic problems
 On anticoagulants
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Blood Type, screen and
crossmatch
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Screen and type blood from all trauma patients
with suspected blunt abdominal injury
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Initial crossmatch on a minimum of 4 units
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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
Diagnostic Adjuncts
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Plain films
FAST ( focused abdominal sonography
for trauma)
CT studies
DPL
Plain Radiographs
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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
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Transverse fractures of vertebral bodies suggests
a higher likelihood of blunt injury to the bowel
FAST (focused assessment with
sonography for trauma)
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Used to evaluate for abdominal injury in
blunt trauma since the 1970’s
Bedside ultrasound is rapid, portable, and
noninvasive
Interpreted as positive if fluid found in
any of the 4 acoustic windows
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An exam is indeterminate if any window
cannot be adequately assessed
FAST
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Assumes that all clinically significant abdominal injuries
are associated with hemoperitoneum
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In reality, detection of free fluid is based on other factors
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Body habitus, injury location, presence of clotted blood, position
of patient and amount of free fluid present
Minimum threshold for detecting free fluid
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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 < 250 ml of intraperitoneal fluid
The 4 acoustic windows
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Pericardiac
Perihepatic
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Perisplenic
Pelvic
FAST: Accuracy
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For identifying hemoperitoneum in blunt
abdominal trauma
Sensitivity 76-90%
 Specificity 95-100%
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Sensitivity increases for clinically
significant hemoperitoneum
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Rozycki et al; US the most sensitive and
specific modality for the evaluation of the
hypotensive patient with blunt abdominal
trauma
FAST: Strengths and Limitations
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Strengths
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Rapid (~ 2 min )
Portable
Relatively inexpensive
Technically simple, easy to
train ( studies show
competence can be
achieved after ~ 30 studies
Can be performed serially
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Limiations
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Does not typically ID
source of bleeding, or
detect injuries that do not
cause hemoperitoneum
Limited in detection of
intraperitoneal fluid (<250
mL)
Poor at detecting bowel
and mesenteric damage
Difficult to assess
retroperitoneum
Limited by body habitus in
the obese
Diagnostic Peritoneal Lavage
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98% sensitive for intraperitoneal bleeding
( ATLS)
Open or closed (Seldinger); usually
infraumbilical
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Supraumbilical in pregnancy and pelvic
fracture
Free aspiration of blood, GI contents, or
bile in hemodynamically unstable patient
requires laparotomy
Performing DPL
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Methods include open, semi open and
closed procedures
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More typical to perform an open procedure if
there are relative contraindications
How FAST is it ??
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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 < 100,000 RBC’s/mL, > 500 WBC’s/mL,
elevated amylase content, bile, bacteria,
vegetable matter or urine
 Delayed decision making process if sample is
sent to lab
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DPL: Advantages vs Disadvantages
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Disadvantages
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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 nontherapeutic laparotomy
rate ( Bain et al; suggests
numbers as high as 36%)
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Advantages
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Answers question quickly if
there is > 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 )
The Role of DPL
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DPL regarded by many authors as
obsolete
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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
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If fluid is found, DPL can help figure out what
it is and where it is coming from –but cannot
ID the exact source
The Abdomen and Pelvic CT
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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
CT: Strengths and Limitations
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Strengths
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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
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Limitations
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Time consuming and
typically involve leaving
the department
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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
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
EAST Algorithm: Unstable
EAST Algorithm: Stable
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
Solid Organ Injuries
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Spleen
Liver
Pancreas
Spleen Injury
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Most commonly injured organ
25% of blunt abdominal injuries
Signs and symptoms often subtle
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Left lower rib fractures
Non operative management in
hemodynamically stable patients
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Immunologic function has promoted salvage
of the spleen rather than splenectomy
Spleen Injury
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Non-operative management attempted in
60-80%
85-94% successful
 2/3 will fail nonoperative mgmt within the
first 24 hours
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Salvage rates decrease with injury
severity
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Injury grade is not predictive of who will fail
Approx 10% will worsen as outpatient
Hepatic Injury
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Relatively fixed position
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2nd most common organ injured
15-20% of blunt abdominal injuries
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Suspect in right lower chest injuries, rib fractures 710
Driving and fighting ( not necessarily at the same
time )
Responsible for 50% of deaths
Non-operative management in
hemodynamically stable patients
Hepatic Injury
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Grade of Injury does not necessarily
predict non operative failures
Failure rates approximately 2%
If stable with ongoing bleeding –
angiographic embolization
Pancreas Injury
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Isolated injury to this organ is uncommon
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Missed injuries do occur
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More frequently associated with liver injury
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
Bowel and Mesenteric Injury
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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
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Difficult to diagnose
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Seatbelt sign present in 21%
Bowel Injuries
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Most Common Sites of Injury
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Jejunum, ileum > 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
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CT findings: Bowel and Mesentery
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Signs of injury on CT
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Bowel – Direct
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Bowel – Indirect
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Free air
Focal bowel wall thickening, wall enhancement
Mesentery – Direct
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Bowel wall disruption
Oral contrast extravasation (typically forego this in trauma
scenarios)
IV contrast extravasation
Mesentery – Indirect
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Diffuse bowel wall thickening, enhancement
Mesenteric hematoma
CT in Bowel and Mesentery Injury
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CT is currently best imaging tool
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DPL is more sensitive (for bowel injury) but
invasive – minimal role in mesentery injury
CT sensitivity
94% for bowel injury
 96% for mesentery injury
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Diaphragmatic Injury
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Diaphragm rupture rarely occurs as an
isolated injury
Pelvic fracture
 Splenic rupture
 Liver laceration
 Thoracic aorta injury
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Only 40-50% are diagnosed immediately
Diaphragm Rupture
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Uncommon – fewer than 5%
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Mechanism
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80-90% occur due to MVC
Left lateral impact – 3x more likely than
frontal impact
80-90% occur on the left
Penetrating Trauma: Historic
Timeline
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Before WWI managed expectantly
During WWII studies showed early
laparotomy improved survival
By late 1950’s laparotomy became
standard
In 1960’s Shaftan suggested selective
mgmt of stab wounds after observing an
increased rate of ex laps with no
identifiable injuries
Penetrating Abdominal Injury
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Implies either a GSW or stab wound has
penetrated the abdominal cavity
GSW’s associated with high incidence of
injury and typically require laparotomy
 Stab wounds associated with lower incidence
and may be expectantly managed
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Relevant Anatomy
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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
Penetrating Abdominal Trauma in
the ED
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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
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Penetrating Trauma: 3 Categories
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Presentation
Pulseless
Hemodynamically
Unstable
Hemodynamically
Stable
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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
The Pulseless Patient
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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
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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
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The Hemodynamically Unstable
Patient
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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
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For questions regarding whether
abdomen is source or site of bleed
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FAST, DPL can be undertaken
Penetrating Abdominal Injuries in
the Unstable Patient
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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
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The Hemodynamically Stable
Patient
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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
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Adjuncts to Identifying Injury
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CXR
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Nasogastric Tube
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Blood drained from the stomach will identify gastric
injury
Urinary Catheter
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May ID subdiaphragmatic air –signals peritoneal
penetration and warrants further investigation
Macroscopic hematuria indicates a bladder or renal
injury
Rectal Examination
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Rectal blood indicates a rectal or sigmoid
penetration
Options for Management
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Serial Physical Examinations
Local Wound Exploration
Diagnostic Peritoneal Lavage
Ultrasound ( FAST)
CT
Laparoscopy
Laparotomy
Serial Physical Examinations
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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
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Local Wound Exploration
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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
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May lead to high non therapeutic lap rate
Diagnostic Peritoneal Lavage
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Sensitivity is 87-100%, specificity is 52-89%
Role of DPL in stable patient differs from that
in the unstable patient
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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
FAST
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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
CT Scan
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Most studies recommend a multislice
scanner with triple contrast protocol
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IV, oral and rectal
CT gives best assessment of
retroperitoneal structures
Laparoscopy
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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
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It is the diagnostic method of choice for
suspected diaphragmatic injuries
Laparotomy
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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
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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
Special Situations:
Thoracoabdominal Junction
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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
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Special Situations: Flank or Back
Wounds
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Flank or Back Wounds
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Associated with retroperitoneal injuries –
including the colon, kidney and lumbar
vessels
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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
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Serial PE’s should be extended to 72 hours if
colon injury is suspected
Special Situations: Wound to
Buttock or Perineum
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Buttock / Perineum wounds
Most dangerous occult injury in this area is to
the rectum
 Any penetrating injury to the gluteal region
carries this risk
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DRE is inadequate and full proctoscopy
and sigmoidoscopy should be performed
Case 1
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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
Trauma Assessment
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P 97; BP 86/50; O2 sats 92%
Unresponsive
Primary Survey
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Secondary Survey
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Management ?
No abdominal distention, BS present
CXR, FAST done during secondary survey
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Pulmonary contusions, rib fractures on left 10-12
FAST negative
Management
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Trauma activation
Secure airway, c-spine immobilization
2 large bore IV’s with 2 L of fluid
Exposure to evaluate completely
Secondary exam
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How reliable is abdominal exam ?
Hemacue is 11, BG is 130
CXR
FAST
Management
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Patient received 2 liters of NS with
stabilization of BP
VSS – HR 86; BP 100/60; O2 sats 100% on
ventilator
FAST is repeated --
Second FAST
CT or OR ?
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Should patient go to OR or CT ?
Vitals have stabilized
Hemacue has dropped to 9.0 and a unit of
PRBC’s has been started
CT scan
Case 2
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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%
Assessment and Management
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Level B trauma activation
Establish 2 large bore IV lines
Primary Survey
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Secondary Survey
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ABCDE, no heavy bleeding from wounds
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
Management
How would you manage this patient ?
Case 3
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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%
Management
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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
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Management
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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 ?

Thank You