Abdominal trauma: Difference between revisions

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==Background ==
==Background==
*>35% of blunt trauma patients thought to have a "benign abdomen" end up needing surgery
*Typically divided into penetrating and abdominal trauma
*Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen
*Gun shot wounds that penetrate the peritoneum virtually all have intra-abdominal injury requiring surgery
**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
**Small bowel most commonly injured


==Clinical Features ==
{{Hemorrhagic shock classes}}
===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===
==Clinical Features==
*Signs/symptoms due to blood loss and peritoneal contamination
[[File:PMC4818312 gr2.png|thumb|Seat-belt sign after motor vehicle collision.]]
*Seat belt sign, peritoneal signs
*Typically, abdominal pain after trauma (blunt or penetrating)
*Free air on CXR
*Lap Belt Injuries often with Chance fracture
 
===[[Retroperitoneal hemorrhage|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
 
===[[Diaphragm 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==
==Differential Diagnosis==
{{Abdominal trauma DDX}}
{{Abdominal trauma DDX}}


==Diagnosis==
==Evaluation==
===Imaging ===
{{ATLS abd trauma diagnosis algorithm}}
*Ultrasound ([[Ultrasound: FAST|FAST]])  
 
**Sensitivity increases with serial exams
===Imaging Tests===
**Cannot reliably evaluate retroperitoneum / hollow viscous injury  
[[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  
**Consider triple-contrast (IV, PO, PR) if concern for GI trauma
**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


{{ATLS abdominal trauma diagnosis algorithm}}
==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


==Management==
''Nonoperative management is the norm in children but not necessarily in adults''
===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)


{| class="wikitable"
==Disposition==
|-
===Discharge===
| <br>
*CT scan of the abdomen and pelvis negative, normotensive
| '''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  
**[[FAST]] neg, responding to [[IVFs]], normotensive
*Penetrating  
*Penetrating  
**Knife: If local wound exploration shows no violation of ant fascia, suture lac and discharged
**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
*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 ==
==See Also==
*[[Trauma (main)]]
*[[Trauma (main)]]
*[[Trauma in pregnancy]]
*[[Trauma in pregnancy]]
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*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]]


[[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

Seat-belt sign after motor vehicle collision.
  • Typically, abdominal pain after trauma (blunt or penetrating)

Differential Diagnosis

Abdominal Trauma

Evaluation

ATLS Blunt Abdominal Trauma Algorithm

  • Unstable
    • FAST to search for free fluid (vs. DPL if unavailable)
      • Positive: Exploratory laparotomy
      • Negative: CT scan
  • Stable
    • CT scan
      • Exploratory laparotomy, angiographic embolization, conservative management as indicated

Imaging Tests

Positive FAST (RUQ)
  • 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
  • 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

  • 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.
  1. 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}}