Abdominal trauma: Difference between revisions
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**Lower sensitivity in the setting of pelvic fractures | **Lower sensitivity in the setting of pelvic fractures | ||
*CT | *CT | ||
**Consider triple-contrast (IV, PO, PR) if concern for GI trauma | **Consider triple-contrast (IV, PO, PR) if concern for GI trauma or penetrating flank or back trauma | ||
{{ATLS abd trauma diagnosis algorithm}} | {{ATLS abd trauma diagnosis algorithm}} |
Revision as of 22:41, 15 April 2017
Background
- >35% of blunt trauma patients thought to have a "benign abdomen" end up needing surgery
- Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen
- Not appropriate for flank or back wounds
- Knife
- Benign initial exam in 20% of patients
- Liver most commonly injured in stab wounds
- GSW virtually all have intra-abdominal injury requiring surgery
- Small bowel most commonly injured
Classes of hemorrhagic shock[1]
Class | I | II | III | IV |
---|---|---|---|---|
Approximate blood loss | <15% | 15-30% | 30-40% | >40% |
Heart rate | ↔ | ↔/↑ | ↑ | ↑↑ |
Blood pressure | ↔ | ↔ | ↔/↓ | ↓ |
Pulse Pressure (mmHg) | ↔ | ↓ | ↓ | ↓ |
Respiratory Rate (per min) | ↔ | ↔ | ↔/↑ | ↑ |
Urine Output (mL/hr) | ↔ | ↔ | ↓ | ↓↓ |
Glasgow coma scale score | ↔ | ↔ | ↓ | ↓ |
Base deficit^ | 0 to -2 mEq/L | -2 to -6 mEq/L | -6 to -10 mEq/L | -10 or less mEq/L |
Need for blood products | Monitor | Possible | Yes | Massive transfusion protocol |
^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.
Clinical Features
Solid Organ Injuries
- Signs/symptoms due to blood loss
- May bleed slowly / delayed onset of shock
- Spleen most likely solid organ injured
Hollow visceral injuries
- Signs/symptoms due to blood loss and peritoneal contamination
- Seat belt sign, peritoneal signs
- Free air on CXR
- Lap Belt Injuries often with Chance fracture
Retroperitoneal Injuries
- Signs/symptoms may be subtle or completely absent initially
- Duodenal rupture is often contained within the retroperitoneum
- Pancreatic rupture may be initially asymptomatic / negative CT /negative lipase
- Grey-Turner sign: flank brusing, often associated with pancreatitis or pancreatic hemorrhage
- Cullen’s sign: subcutaneous bruising and edema, often seen with AAA or pancreatic injury
Diaphragmatic Injuries
- Symptoms
- shortness of breath, Kehr Sign: shoulder pain from diaphragm or peritoneal irritation)
- Generally related to degree of displacement of abdominal viscera into thorax
- CXR: NGT curled in chest, abdominal organ herniation, thoracic aorta rupture
Differential Diagnosis
Abdominal Trauma
- Abdominal compartment syndrome
- Diaphragmatic trauma
- Duodenal hematoma
- Genitourinary trauma
- Liver trauma
- Pelvic fractures
- Retroperitoneal hemorrhage
- Renal trauma
- Splenic trauma
- Trauma in pregnancy
- Ureter trauma
Evaluation
Imaging
- Ultrasound (FAST)
- Indicated for hemodynamically unstable trauma patients
- Sensitivity increases with serial exams
- Cannot reliably evaluate retroperitoneum / hollow viscous injury
- Lower sensitivity in the setting of pelvic fractures
- CT
- Consider triple-contrast (IV, PO, PR) if concern for GI trauma or penetrating flank or back trauma
ATLS Blunt Abdominal Trauma Algorithm
- Unstable
- Stable
- CT scan
- Exploratory laparotomy, angiographic embolization, conservative management as indicated
- CT scan
Management
Nonoperative management is the norm in children but not necessarily in adults
Indications for laparotomy
Blunt | Penetrating | |
Absolute | Anterior abdominal injury with hypotension | Injury to abdomen, back, and flank with hypotension |
Abdominal wall disruption | Abdominal tenderness | |
Peritonitis | GI evisceration | |
Free air under diaphragm on chest radiograph | High suspicion for transabdominal trajectory after gunshot wound | |
Positive FAST or DPL in hemodynamically unstable patient | CT-diagnosed injury requiring surgery (i.e., ureter or pancreas) | |
CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury) | ||
Relative | Positive FAST or DPL in hemodynamically stable patient | |
Solid visceral injury in stable patient | ||
Hemoperitoneum on CT without clear source |
Disposition
Stable
- CT scan of the abdomen and pelvis
- Penetrating
- Knife: If local wound exploration shows no violation of ant fascia, suture lac and discharged
- If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation
- Angioembolization for hemodynamically stable patients with suspected bleed
Unstable
- IR vs Surgery
- isolated bleed for angioembolization
- polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy
See Also
References
- Shah, Essential Emergency Trauma, pgs 143-148
- Bailitz J, Bokhari F, Scaletta TA, Schaider J. Emergent Management of Trauma. New York: The McGraw-Hill Company, 2011: pg 193.
- ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81