Abdominal trauma: Difference between revisions
Neil.m.young (talk | contribs) (Text replacement - "== " to "==") |
Neil.m.young (talk | contribs) (Text replacement - " ==" to "==") |
||
Line 1: | Line 1: | ||
==Background | ==Background == | ||
*>35% of blunt trauma patients thought to have a "benign abdomen" end up needing surgery | *>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 | *Local wound exploration for ant abdominal stab wounds accurately evaluates the abdomen | ||
Line 9: | Line 9: | ||
**Small bowel most commonly injured | **Small bowel most commonly injured | ||
==Clinical Features | ==Clinical Features == | ||
===Solid Organ Injuries=== | ===Solid Organ Injuries=== | ||
*S/s due to blood loss | *S/s due to blood loss | ||
Line 37: | Line 37: | ||
{{Abdominal trauma DDX}} | {{Abdominal trauma DDX}} | ||
==Diagnosis == | ==Diagnosis== | ||
===Imaging | ===Imaging === | ||
*Ultrasound ([[Ultrasound: FAST|FAST]]) | *Ultrasound ([[Ultrasound: FAST|FAST]]) | ||
**Sensitivity increases with serial exams | **Sensitivity increases with serial exams | ||
Line 47: | Line 47: | ||
{{ATLS abd trauma diagnosis algorithm}} | {{ATLS abd trauma diagnosis algorithm}} | ||
==Management == | ==Management== | ||
''Nonoperative management is the norm in children but not necessarily in adults'' | ''Nonoperative management is the norm in children but not necessarily in adults'' | ||
===Indications for laparotomy=== | ===Indications for laparotomy=== | ||
Line 94: | Line 94: | ||
|} | |} | ||
==Disposition | ==Disposition == | ||
===Stable=== | ===Stable=== | ||
*CT scan of the abdomen and pelvis | *CT scan of the abdomen and pelvis | ||
Line 108: | Line 108: | ||
**polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy | **polytrauma, hypotension, free intraperitoneal fluid - immediate exploratory laparotomy | ||
==See Also | ==See Also == | ||
*[[Trauma (main)]] | *[[Trauma (main)]] | ||
*[[Trauma in pregnancy]] | *[[Trauma in pregnancy]] | ||
*[[Thoracic and lumbar spine trauma]] | *[[Thoracic and lumbar spine trauma]] | ||
==References == | ==References== | ||
*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. | ||
[[Category:Trauma]] | [[Category:Trauma]] |
Revision as of 10:28, 8 July 2016
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
Clinical Features
Solid Organ Injuries
- S/s due to blood loss
- May bleed slowly / delayed onset of shock
- Spleen most likely solid organ injured
Hollow visceral injuries
- S/s 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
- S/s may be subtle or completely absent initially
- Duodenal rupture is often contained w/in 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
- SOB, 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
Diagnosis
Imaging
- Ultrasound (FAST)
- Sensitivity increases with serial exams
- Cannot reliably evaluate retroperitoneum / hollow viscous injury
- CT
- Consider triple-contrast (IV, PO, PR) if concern for GI 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.