abdominal trauma begashaw m (md). anatomy abdominal trauma two mechanisms _blunt usually causes...
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Abdominal Trauma
Begashaw M (MD)
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Anatomy
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Abdominal Trauma
Two mechanisms
_Bluntusually causes solid organ injury (spleen injury is most common)
_Penetratingusually causes hollow organ injury or liver injury (most common)
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Mechanism of Injury
Blunt Force Trauma Penetrating Trauma
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Mechanism of Injury Africa style
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Mechanism of Injury
Blunt– Speed– Nature of Impact– Position in vehicle– Ejection– Intrusion– Seatbelt– Airbag
Penetrating– Type of weapon– Distance – Number and
location of wounds– Trajectory– Energy– Blast effect
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BLUNT TRAUMA
results in two types of hemorrhage
- intra-abdominal bleeding
- retroperitoneal bleedingadopt high clinical suspicion of bleeding in
multi-system trauma
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Examination
Abdomen
Inspect: contusions, abrasions, seatbelt sign, distention
Auscultate: bruits,bowel sounds
Palpate: tenderness, rebound tenderness, rigidity, guarding
DRE: rectal tone, blood, bone fragments,prostate location
Placement - NG, foley catheter
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Commonly injured organs
SpleenLiverSmall Bowel
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Assessment of abdominal trauma
Difficult due to:
_Altered sensorium (head injury, alcohol)
_Altered sensation (spinal cord injury)
_Injury to adjacent structures (pelvis, chest)
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Investigations
Labs: CBC, electrolytes,cross & type, glucose, creatinine, amylase, liver enzymes
Imaging
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Imaging
Imaging strengths limitations
X-ray Erect CXR Soft tissue not visualized
CT scan Most specific test Radiation,cannot use if hemodynamic instability
Diagnostic peritoneal Lavage
Most sensitive testTest for intra abdominal bleeding
Retroperitoneal hemorrhage, diaphragmatic rupture
Ultrasound FAST Free fluid, Rapid, pericardium, plura
Specific organ injury
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FAST
Focused assessment for the sonographic assessment of trauma
Assess for intraperitoneal fluid
o Right upper quadrant
o Left upper quadrant
o Suprapubic region Fluid in subphrenic, subhepatic spaces or Pouch of
Douglas in hypotensive patient Confirms likely need for emergency laparotomy
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FAST
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Criteria for positive DPL
>10 cc gross bloodBile, bacteria. foreign materialRBC count >I 00,000 WBC >500 Amylase > 1751U
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Imaging
Equivocal abdominal examination, suspected intra-abdominal injury
Multiple trauma Unexplained shock/hypotensionFractures of lower ribs, pelvis, spinepositive FAST
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Management
General: ABCs, fluid resuscitation and stabilization Surgical: watchful wait vs laparotomy Solid organ injuries: decision based on
hemodynamic stability, not the specific injuries Hemodynamically unstable or persistently high
transfusion requirements: laparotomy Hollow organ injuries: laparotomy Even if low suspicion on injury: admit and observe
for 24 hours
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Indications for Laparotomy
Free Fluid on FASTUnstable patient with suspected abdominal
injuryFree AirDiaphragm RupturePeritonitisPositive findings on CT Scan
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PENETRATING TRAUMA
High risk of gastrointestinal perforation and sepsis History: size of blade, calibre/distance from gun,
route of entry Local wound exploration under direct vision may
determine lack of peritoneal penetration (not reliable in inexperienced hands) with the following exceptions:
-thoracoabdominal region (may cause pneumothorax)
-back or flanks (muscles too thick)
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Penetrating Trauma
Overall condition of the patient
Local wound exploration
DPL?
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Penetrating abdominal trauma
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Laparomy in penetrating injury
ShockPeitonitisEviserationFree air in abdomenBlood in NG tube, Foley catheter, or on
rectal exam
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Management
General: ABCs, fluid resuscitation and stabilization
Gunshot wounds-always require laparotomy