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Trauma Conference Trauma Conference January 9 January 9 th th , 2006 , 2006 Greg Feldman, MD Greg Feldman, MD PGY1, General Surgery Department PGY1, General Surgery Department Stanford Medical Center Stanford Medical Center Blunt Abdominal Trauma: Blunt Abdominal Trauma: Evaluation Evaluation
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Abdominal Trauma

Oct 31, 2014

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Abdominal Trauma
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Page 1: Abdominal Trauma

Trauma ConferenceTrauma Conference

January 9January 9thth, 2006, 2006

Greg Feldman, MDGreg Feldman, MD

PGY1, General Surgery DepartmentPGY1, General Surgery Department

Stanford Medical CenterStanford Medical Center

Blunt Abdominal Trauma:Blunt Abdominal Trauma:EvaluationEvaluation

Page 2: Abdominal Trauma

OutlineOutline

Anatomic definition of abdomenAnatomic definition of abdomen Mechanisms of injury in blunt traumaMechanisms of injury in blunt trauma Typical injury patternsTypical injury patterns Assessment of blunt abdominal traumaAssessment of blunt abdominal trauma Diagnostic algorithmsDiagnostic algorithms

Page 3: Abdominal Trauma

Abdomen: anatomic boundariesAbdomen: anatomic boundaries

External:External: Anterior abdomen: transnipple line superiorly, inguinal ligaments and Anterior abdomen: transnipple line superiorly, inguinal ligaments and

symphasis pubis inferiorly, anterior axillary lines laterally.symphasis pubis inferiorly, anterior axillary lines laterally. Flank: between anterior and posterior axillary lines from 6th intercostals Flank: between anterior and posterior axillary lines from 6th intercostals

space to iliac crest.space to iliac crest. Back: Posterior to posterior axillary lines, from tip of scapulae to iliac crests.Back: Posterior to posterior axillary lines, from tip of scapulae to iliac crests.

Internal:Internal: Upper peritoneal cavity: covered by lower aspect of bony thorax. Includes Upper peritoneal cavity: covered by lower aspect of bony thorax. Includes

diaphragm, liver, spleen, stomach, transverse colon.diaphragm, liver, spleen, stomach, transverse colon. Lower peritoneal cavity: small bowel, ascending and descending colon, Lower peritoneal cavity: small bowel, ascending and descending colon,

sigmoid colon, and (in women) internal reproductive organs.sigmoid colon, and (in women) internal reproductive organs. Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women) Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women)

internal reproductive organs.internal reproductive organs. Retroperitoneal space: posterior to peritoneal lining of abdomen. Abdominal Retroperitoneal space: posterior to peritoneal lining of abdomen. Abdominal

aorta, IVC, most of duodenum, pancreas kidneys, ureters, and posterior aorta, IVC, most of duodenum, pancreas kidneys, ureters, and posterior aspects of ascending and descending colon.aspects of ascending and descending colon.

Page 4: Abdominal Trauma

Mechanisms of injuryMechanisms of injury

Compression, crush, or sheer injury to abdominal viscera Compression, crush, or sheer injury to abdominal viscera deformation of solid or hollow organs, rupture (e.g. small deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus)bowel, gravid uterus)

Deceleration injuries: differential movements of fixed and Deceleration injuries: differential movements of fixed and nonfixed structures (e.g. liver and spleen lacs at sites of nonfixed structures (e.g. liver and spleen lacs at sites of supporting ligaments)supporting ligaments)

Page 5: Abdominal Trauma

Common injury patternsCommon injury patterns

In patients undergoing laparotomy for blunt trauma, most frequently In patients undergoing laparotomy for blunt trauma, most frequently injured organs are spleen (40-55%), liver (35-45%), and small bowel (5-injured organs are spleen (40-55%), liver (35-45%), and small bowel (5-10%). (ATLS, 2001)10%). (ATLS, 2001)

Duodenum:Duodenum: Classically, frontal-impact MVC with unrestrained driver; or direct blow to Classically, frontal-impact MVC with unrestrained driver; or direct blow to

abdomen.abdomen. Bloody gastric aspirate, retroperitoneal air on XR or CTBloody gastric aspirate, retroperitoneal air on XR or CT Confirmed with upper GI series or double contrast CTConfirmed with upper GI series or double contrast CT

Small bowel injury:Small bowel injury: Generally from sudden deceleration with subsequent tearing near fixed Generally from sudden deceleration with subsequent tearing near fixed

points of attachment.points of attachment. Often associated with seat belt sign, lumbar distraction fracture (Chance Often associated with seat belt sign, lumbar distraction fracture (Chance

fracture)fracture) DPL superior to FAST or CT for diagnosis.DPL superior to FAST or CT for diagnosis.

Page 6: Abdominal Trauma

Common injury patterns (2)Common injury patterns (2)

Pancreas:Pancreas: Direct epigastric blow compressing pancreas against vertebral column.Direct epigastric blow compressing pancreas against vertebral column. Early normal serum amylase does NOT exclude major pancreatic trauma.Early normal serum amylase does NOT exclude major pancreatic trauma. CT with PO/IV contrast – NOT particularly sensitive in immediate post-CT with PO/IV contrast – NOT particularly sensitive in immediate post-

injury period.injury period.

Diaphragm:Diaphragm: Most commonly, 5-10 cm rupture involving posterolateral hemidiaphragm.Most commonly, 5-10 cm rupture involving posterolateral hemidiaphragm. Noted on CXR: blurred or elevated hemidiaphragm, hemothorax, GT in Noted on CXR: blurred or elevated hemidiaphragm, hemothorax, GT in

chestchest

Genitourinary:Genitourinary: Anterior injuries (below UG diaphragm): usually from straddle impact.Anterior injuries (below UG diaphragm): usually from straddle impact. Posterior injuries (above UG diaphragm): in patient with multisystem Posterior injuries (above UG diaphragm): in patient with multisystem

injuries and pelvic fractures.injuries and pelvic fractures.

Page 7: Abdominal Trauma

Common injury patterns (3)Common injury patterns (3)

Solid organ injurySolid organ injury Laceration to liver, spleen, or kidneyLaceration to liver, spleen, or kidney Injury to one of these three + hemodynamic instability: considered Injury to one of these three + hemodynamic instability: considered

indication for urgent laparotomyindication for urgent laparotomy Isolated solid organ injury in hemodynamically stable patient: can Isolated solid organ injury in hemodynamically stable patient: can

often be managed nonoperatively.often be managed nonoperatively.

Pelvic fractures:Pelvic fractures: Suggest major force applied to patient.Suggest major force applied to patient. Usually auto-ped, MVC, or motorcycleUsually auto-ped, MVC, or motorcycle Significant association with intraperitoneal and retroperitoneal Significant association with intraperitoneal and retroperitoneal

organs and vascular structures.organs and vascular structures.

Page 8: Abdominal Trauma

Restraining devicesRestraining devices

Lap seat beltLap seat belt Mesenteric tear or avulsionMesenteric tear or avulsion Rupture of small bowel or colonRupture of small bowel or colon Iliac artery or abdominal aorta thrombosisIliac artery or abdominal aorta thrombosis Chance fracture of lumbar vertebrae (hyperflexion)Chance fracture of lumbar vertebrae (hyperflexion)

Shoulder HarnessShoulder Harness Rupture of upper abdominal visceraRupture of upper abdominal viscera Intimal tear or thrombosis in innominate, carotid, subclavian, or vertebral arteriesIntimal tear or thrombosis in innominate, carotid, subclavian, or vertebral arteries Fracture or dislocation of C-spineFracture or dislocation of C-spine Rib fracturesRib fractures Pulmonary contusionPulmonary contusion

Air BagAir Bag Corneal abrasions, keratitisCorneal abrasions, keratitis Abrasions of face, neck, chestAbrasions of face, neck, chest Cardiac ruptureCardiac rupture C or T-spine fractureC or T-spine fracture

Page 9: Abdominal Trauma

Assessment: HistoryAssessment: History

MechanismMechanism Symptoms, events, PMH, Meds, EtOH/drugsSymptoms, events, PMH, Meds, EtOH/drugs MVC:MVC:

SpeedSpeed Type of collision (frontal, lateral, sideswipe, rear, Type of collision (frontal, lateral, sideswipe, rear,

rollover)rollover) Vehicle intrusion into passenger compartmentVehicle intrusion into passenger compartment Types of restraintsTypes of restraints Deployment of air bagDeployment of air bag Patient's position in vehiclePatient's position in vehicle

Page 10: Abdominal Trauma

Assessment: Physical ExamAssessment: Physical Exam

Inspection, auscultation, percussion, palpationInspection, auscultation, percussion, palpation Inspection: abrasions, contusions, lacerations, deformityInspection: abrasions, contusions, lacerations, deformity

Grey-Turner, Kehr, Balance, CullenGrey-Turner, Kehr, Balance, Cullen

Auscultation: careful exam advised by ATLS. Auscultation: careful exam advised by ATLS. (Controversial utility in trauma setting.)(Controversial utility in trauma setting.)

Percussion: subtle signs of peritonitis; tympany in gastric Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneumdilatation or free air; dullness with hemoperitoneum

Palpation: elicit superficial, deep, or rebound tenderness; Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guardinginvoluntary muscle guarding

Page 11: Abdominal Trauma

Physical Exam: EponymsPhysical Exam: Eponyms

Grey-Turner sign:Grey-Turner sign: Bluish discoloration of lower flanks, lower back; associated with Bluish discoloration of lower flanks, lower back; associated with

retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.retroperitoneal bleeding of pancreas, kidney, or pelvic fracture. Cullen sign:Cullen sign:

Bluish discoloration around umbilicus, indicates peritoneal bleeding, Bluish discoloration around umbilicus, indicates peritoneal bleeding, often pancreatic hemorrhage.often pancreatic hemorrhage.

Kehr sign:Kehr sign: L shoulder pain while supine; caused by diaphragmatic irritation L shoulder pain while supine; caused by diaphragmatic irritation

(splenic injury, free air, intra-abd bleeding)(splenic injury, free air, intra-abd bleeding) Balance sign:Balance sign:

Dull percussion in LUQ. Sign of splenic injury; blood accumulating Dull percussion in LUQ. Sign of splenic injury; blood accumulating in subcapsular or extracapsular spleen.in subcapsular or extracapsular spleen.

Page 12: Abdominal Trauma

Diagnostic adjunctsDiagnostic adjuncts

Labs: BMP, CBC, coags, b-HCG, amy/lip, U/A, tox screen, Labs: BMP, CBC, coags, b-HCG, amy/lip, U/A, tox screen, T&CT&C

Plain films: CXR, pelvis; abd films generally lower priorityPlain films: CXR, pelvis; abd films generally lower priority DPLDPL FASTFAST CTCT

Page 13: Abdominal Trauma

Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage

98% sensitive for intraperitoneal bleeding (ATLS)98% sensitive for intraperitoneal bleeding (ATLS) Open or closed (Seldinger); usually infraumbilical, but may be Open or closed (Seldinger); usually infraumbilical, but may be

supraumbilical in pelvic frxs or advanced pregnancy.supraumbilical in pelvic frxs or advanced pregnancy. Free aspiration of blood, GI contents, or bile in demodynamically Free aspiration of blood, GI contents, or bile in demodynamically

abnormal pt: indication for laparotomyabnormal pt: indication for laparotomy If gross blood (> 10 mL) or GI contents not aspirated, perform lavage If gross blood (> 10 mL) or GI contents not aspirated, perform lavage

with 1000 mL warmed LR. Allow to mix, compress abdomen and with 1000 mL warmed LR. Allow to mix, compress abdomen and logross paient, the sent to lab. + test: >100,000 RBC/mm3, >500 logross paient, the sent to lab. + test: >100,000 RBC/mm3, >500 WBC/mm3, Gram stain with bacteria.WBC/mm3, Gram stain with bacteria.

Alters subsequent examination of patientAlters subsequent examination of patient

Has been somewhat superceded by FAST in common use; now generally Has been somewhat superceded by FAST in common use; now generally performed in unstable patients with intermediate FAST exams, or with performed in unstable patients with intermediate FAST exams, or with suspicion for small bowel injury.suspicion for small bowel injury.

Page 14: Abdominal Trauma

FAST: Strengths and LimitationsFAST: Strengths and LimitationsStrengthsStrengths Rapid (~2 mins)Rapid (~2 mins) PortablePortable InexpensiveInexpensive Technically simple, easy to train Technically simple, easy to train

(studies show competence can be (studies show competence can be achieved after ~30 studies)achieved after ~30 studies)

Can be performed seriallyCan be performed serially Useful for guiding triage decisions Useful for guiding triage decisions

in trauma patientsin trauma patients

LimitationsLimitations Does not typically identify source of Does not typically identify source of

bleeding, or detect injuries that do bleeding, or detect injuries that do not cause hemoperitoneumnot cause hemoperitoneum

Requires extensive training to assess Requires extensive training to assess parenchyma reliablyparenchyma reliably

Limited in detecting <250 cc Limited in detecting <250 cc intraperitoneal fluidintraperitoneal fluid

Particularly poor at detecting bowel Particularly poor at detecting bowel and mesentery damage (44% and mesentery damage (44% sensitivity)sensitivity)

Difficult to assess retroperitoneumDifficult to assess retroperitoneum Limited by habitus in obese patientsLimited by habitus in obese patients

Page 15: Abdominal Trauma

FAST: AccuracyFAST: Accuracy

For identifying hemoperitoneum in blunt abdominal trauma:For identifying hemoperitoneum in blunt abdominal trauma: Sensitivity 76 - 90%Sensitivity 76 - 90% Specificity 95 - 100%Specificity 95 - 100%The larger the hemoperitoneum, the higher the sensitivity. So The larger the hemoperitoneum, the higher the sensitivity. So

sensitivity increases for sensitivity increases for clinically significant clinically significant hemoperitoneum.hemoperitoneum.

How much fluid can FAST detect?How much fluid can FAST detect? 250 cc total250 cc total 100 cc in Morison’s pouch100 cc in Morison’s pouch

Page 16: Abdominal Trauma

Does FAST replace CT?Does FAST replace CT?

Only at the extremes.Only at the extremes. Unstable patient, (+) FAST Unstable patient, (+) FAST OR OR Stable patient, low force injury, (-) FAST Stable patient, low force injury, (-) FAST consider consider

observing patient. observing patient.

CT is far more sensitive than FAST for detecting and CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. The gold characterizing abdominal injury in trauma. The gold standard for characterizing intraparenchymal injury.standard for characterizing intraparenchymal injury.

““Death begins with a CT.” Never send an unstable patient to Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be performed during CT. FAST, however, can be performed during resuscitation.resuscitation.

Page 17: Abdominal Trauma

CTCT

EAST level I recommendations (2001):EAST level I recommendations (2001): CT is recommended for evaluation of hemodynamically CT is recommended for evaluation of hemodynamically

stable patients with equivocal findings on physical stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple examination, associated neurologic injury, or multiple extra-abdominal injuries.extra-abdominal injuries.

CT is the diagnostic modality of choice for nonoperative CT is the diagnostic modality of choice for nonoperative management of solid visceral injuries.management of solid visceral injuries.

Page 18: Abdominal Trauma

EAST Algorithm: UnstableEAST Algorithm: Unstable

Eastern Association for the Surgery of Trauma, 2001

Page 19: Abdominal Trauma

EAST Algorithm: StableEAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001

Page 20: Abdominal Trauma

ReferencesReferences

Hoff et al. EAST Practice Management Guidelines Work Group. Hoff et al. EAST Practice Management Guidelines Work Group. Practice Management Guidelines for the Evaluation of Blunt Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma, 2001. www.east.org.Abdominal Trauma, 2001. www.east.org.

American College of Surgeons Committee on Trauma. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors; Student Course Advanced Trauma Life Support for Doctors; Student Course Manual, 7Manual, 7thth edition, 2004. edition, 2004.

Scalea TM, Rodriquez A, Chiu WC. Focused Assessment with Scalea TM, Rodriquez A, Chiu WC. Focused Assessment with Sonography for Trauma (FAST): Results from an International Sonography for Trauma (FAST): Results from an International Consensus Conference. Consensus Conference. J. Trauma J. Trauma 1999;46:466-472.1999;46:466-472.

Yoshii H, Sato M, Yamamoto S. Usefulness and Limitations of Yoshii H, Sato M, Yamamoto S. Usefulness and Limitations of Ultrasonography in the Initial Evaluation of Blunt Abdominal Ultrasonography in the Initial Evaluation of Blunt Abdominal Trauma. Trauma. J. TraumaJ. Trauma 1998;45:45-51. 1998;45:45-51.

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AcknowledgementsAcknowledgements Dr. Shelly ErfordDr. Shelly Erford Dr. Denny JenkinsDr. Denny Jenkins Carol ThomsonCarol Thomson Dr. Natalie KirilchikDr. Natalie Kirilchik Dr. Subarna BiswasDr. Subarna Biswas Drs. Brundage, Spain, and GreggDrs. Brundage, Spain, and Gregg Stanford Medical Center ACS/Trauma ServiceStanford Medical Center ACS/Trauma Service Noah FeinsteinNoah Feinstein Dr. Gillian LiebermanDr. Gillian Lieberman Dr. Jason TracyDr. Jason Tracy