Abdominal trauma: Difference between revisions
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==Background == | ==Background== | ||
* | *Typically divided into penetrating and abdominal trauma | ||
* | *Gun shot wounds that penetrate the peritoneum virtually all have intra-abdominal injury requiring surgery | ||
**Small bowel most commonly injured | **Small bowel most commonly injured | ||
{{Hemorrhagic shock classes}} | |||
=== | ==Clinical Features== | ||
[[File:PMC4818312 gr2.png|thumb|Seat-belt sign after motor vehicle collision.]] | |||
*Typically, abdominal pain after trauma (blunt or penetrating) | |||
* | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Abdominal trauma DDX}} | {{Abdominal trauma DDX}} | ||
== | ==Evaluation== | ||
===Imaging === | {{ATLS abd trauma diagnosis algorithm}} | ||
*Ultrasound ([[ | |||
** | ===Imaging Tests=== | ||
** | [[File:Free fluid.png|thumb|Positive [[FAST]] (RUQ)]] | ||
*Ultrasound ([[FAST exam|FAST]]) | |||
**Indicated '''only''' for hemodynamically unstable trauma patients | |||
***Otherwise CT is indicated for primary imaging | |||
****Ultrasound cannot reliably evaluate retroperitoneum / hollow viscous injury | |||
****Ultrasound has lower sensitivity in the setting of pelvic fractures | |||
***If CT is not available (e.g. low resource area, multiple casualty) can consider serial [[FAST]] exams, which increases sensitivity | |||
****For example, serial abdominal exams with two FAST examinations performed at least 6 hours apart | |||
*CT | *CT | ||
** | **CT with IV contrast only is typical standard | ||
***May consider triple-contrast (IV, PO, PR) if specific concern for viscous perforation, although delay to imaging typically prohibits this as the initial study | |||
==Management== | |||
''Nonoperative management is the norm in children, but not necessarily in adults.'' | |||
*[[ATLS]] algorithm for severe trauma | |||
**Vascular access | |||
**Consider [[blood transfusion]] (and [[massive transfusion protocol]]) + [[TXA]] | |||
**Surgery consult (surgery vs. IR) | |||
**polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy | |||
**isolated bleed for angioembolization | |||
===Indications for laparotomy=== | ===Indications for laparotomy=== | ||
*Blunt | |||
**Anterior abdominal injury with hypotension | |||
**Abdominal wall disruption | |||
**Peritonitis | |||
**Free air under diaphragm on chest radiograph | |||
**Positive FAST or DPL in hemodynamically unstable patient | |||
**CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury) | |||
*Penetrating | |||
**Injury to abdomen, back, and flank with hypotension | |||
**Abdominal tenderness | |||
**GI evisceration | |||
**High suspicion for transabdominal trajectory after gunshot wound | |||
**CT-diagnosed injury requiring surgery (i.e., ureter or pancreas) | |||
==Disposition== | |||
===Discharge=== | |||
*CT scan of the abdomen and pelvis negative, normotensive | |||
==Disposition == | |||
=== | |||
*CT scan of the abdomen and pelvis | |||
*Penetrating | *Penetrating | ||
**Knife: If local wound exploration shows no violation of | **Knife: If local wound exploration shows no violation of anterior fascia, suture laceration and discharge | ||
**If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation | **If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation | ||
==See Also == | ==See Also== | ||
*[[Trauma (main)]] | *[[Trauma (main)]] | ||
*[[Trauma in pregnancy]] | *[[Trauma in pregnancy]] | ||
Line 116: | Line 68: | ||
*Shah, Essential Emergency Trauma, pgs 143-148 | *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. | *Bailitz J, Bokhari F, Scaletta TA, Schaider J. Emergent Management of Trauma. New York: The McGraw-Hill Company, 2011: pg 193. | ||
<references/> | |||
[[Category:Trauma]] | |||
==Videos== | |||
{{#widget:YouTube|id=j5BuHyoeK-U}} | |||
{{#widget:YouTube|id=l8VDztQtHG4}} |
Latest revision as of 04:57, 27 January 2020
Background
- Typically divided into penetrating and abdominal trauma
- Gun shot wounds that penetrate the peritoneum 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
- Typically, abdominal pain after trauma (blunt or penetrating)
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
ATLS Blunt Abdominal Trauma Algorithm
- Unstable
- Stable
- CT scan
- Exploratory laparotomy, angiographic embolization, conservative management as indicated
- CT scan
Imaging Tests
- Ultrasound (FAST)
- Indicated only for hemodynamically unstable trauma patients
- Otherwise CT is indicated for primary imaging
- Ultrasound cannot reliably evaluate retroperitoneum / hollow viscous injury
- Ultrasound has lower sensitivity in the setting of pelvic fractures
- If CT is not available (e.g. low resource area, multiple casualty) can consider serial FAST exams, which increases sensitivity
- For example, serial abdominal exams with two FAST examinations performed at least 6 hours apart
- Otherwise CT is indicated for primary imaging
- Indicated only for hemodynamically unstable trauma patients
- CT
- CT with IV contrast only is typical standard
- May consider triple-contrast (IV, PO, PR) if specific concern for viscous perforation, although delay to imaging typically prohibits this as the initial study
- CT with IV contrast only is typical standard
Management
Nonoperative management is the norm in children, but not necessarily in adults.
- ATLS algorithm for severe trauma
- Vascular access
- Consider blood transfusion (and massive transfusion protocol) + TXA
- Surgery consult (surgery vs. IR)
- polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy
- isolated bleed for angioembolization
Indications for laparotomy
- Blunt
- Anterior abdominal injury with hypotension
- Abdominal wall disruption
- Peritonitis
- Free air under diaphragm on chest radiograph
- Positive FAST or DPL in hemodynamically unstable patient
- CT-diagnosed injury requiring surgery (i.e., pancreatic transection, duodenal rupture, diaphragm injury)
- Penetrating
- Injury to abdomen, back, and flank with hypotension
- Abdominal tenderness
- GI evisceration
- High suspicion for transabdominal trajectory after gunshot wound
- CT-diagnosed injury requiring surgery (i.e., ureter or pancreas)
Disposition
Discharge
- CT scan of the abdomen and pelvis negative, normotensive
- Penetrating
- Knife: If local wound exploration shows no violation of anterior fascia, suture laceration and discharge
- If CT shows a subcutaneous trajectory or minimal retroperitoneal violation, discharge home after period of observation
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
Videos
{{#widget:YouTube|id=j5BuHyoeK-U}} {{#widget:YouTube|id=l8VDztQtHG4}}