chapter 5, abdominal trauma

8/10/2019 Chapter 5, Abdominal Trauma

1/41


2/41

Objectives

Identify key anatomic features of the

abdomen.Describe blunt and penetrating injury

patterns.

Describe the evaluation of the patient withsuspected abdominal injury.


3/41

Objectives times new Roman 42, bold, shadow

Huruf times new Roman 32, bold, shadow

Objectives

Identify and apply the most appropriate

diagnostic and therapeutic procedures.Discuss acute management of pelvic

fracture.


4/41

Key Questions

What priority is abdominal trauma in the

management of the multiply injuredpatient?

Why is the mechanism of injury important?

How do I know if shock is the result of anintraabdominal injury?


5/41

Key Questions

How do I determine if there is an

abdominal injury?Who warrants a celiotomy (laparotomy?)

How do I manage patients with pelvic

fractures?


6/41

External Anatomy


7/41

Lower peritoneal

cavity

Pelvic cavity


8/41


9/41

Abdominal Trauma

What is one of the leading cause of

preventable mortality?

Unrecognizedintraabdominal

injury


10/41

Abdominal trauma priority?

Head and abdominal trauma?

Head, chest, and abdominal trauma?Head, chest, abdominal and extremity

trauma?

Head, chest, abdomen, extremity, andpelvic trauma?


11/41

Mechanism of Injury

Why is it important to know?

It determines what

organs are probablyinjured.


12/41

Blunt Force Mechanism

Compression

Crushing

Shearing

Deceleration (fixed organs)

How does it injure?


13/41

Blunt Force Mechanism

Spleen

Liver

Small bowel

What organs are commonly injured?


14/41

Penetrating Mechanism?

Stab Low energy

Lacerations

Gunshot High energy

Transfer ofkinetic energy

Cavitation

Tumble

Fragments

How does it injuries?


15/41

Penetrating Mechanism

Low Energy Liver

Small bowel

Diaphragm

Colon

High Energy Small bowel

Colon

Liver

Vascular structures

Common injuries?


16/41

Assessment: History

Blunt

Speed

Point of impact

Intrusion

Safety devices

Position

Ejection

Penetrating

Weapon

Distance

Number of wounds


17/41

Assessment: Physical Exam

Inspection

Auscultation

Percussion

Palpation


18/41

Abdominal Trauma

What can compromise the exam?

Alcohol or other drugs

Injuries to brain, spinal cord

Injury to ribs, spine, pelvis


19/41

Assessment: Stab Wound

How do I evaluate and manage the

abdomen of a patient with an anteriorabdominal, lower chest, flank, or back

stab wound?

What is a positive local woundexploration performed by a surgeon?


20/41

Assessment: Penetrating Injury

How do I evaluate and manage perineal,

rectal, vagina, or gluteal penetratinginjuries?


21/41

Assessment: Gunshot Wound

Tangential?

Exit wound?

Likely injuries?

X-rays?

Lab

determinations?

How do I evaluate and manage the

abdomen of a patient with a possible

abdominal GSW?


22/41

Management: Gunshot Wound

Early operation usually is

the best strategy..


23/41

Abdominal injury causes shock?

Evidence of abdominal injury by

mechanism, history, or evaluationHypotension

Positive FAST or grossly positive DPL

Absence of massive hemothorax on

chest x-ray


24/41

Adjunct: Gastric Tube

Relieves distention

Decompresses stomach before DPL

Basilar skull / facial fractures

May induce vomiting /aspiration


25/41

Adjunct: Urinary Catheter

Monitors urinary output

Decompress bladder before DPLDiagnostic


26/41

Adjuncts: Blood / Urine Tests

No mandatory blood tests

Injury Severity and likely injuries

Hemodynamically abnormal: type &crossmatch

Pregnancy testing

Alcohol or other drug testing

Gross hematuria vs microscopic


27/41

Adjuncts: X-ray Studies

Routine

Blunt: AP Chest and Pelvis

Penetrating: AP chest and abdomen

with markers (if hemodinamically

normal)


28/41

Adjuncts: Contrast Studies

Urethrogram

CystogramIVP

GI

Abdominal CT


29/41


30/41

Diagnostic Studies: Penetrating

Lower chest wounds: Serial exams,

thoracoscopy, laparoscopy, or CT scanAnterior abdominal stab wounds:

wound exploration, DPL, or serialexams

Back and flank stab wound:DPL,serial exams, or double- or triplecontrast CT scan


31/41

Indication for celiotomy?

Blunt Trauma

BP, suspect visceral injury

Free air

Diaphragmatic rupture

Peritonitis+ DPL, FAST, or contrast CT


32/41

Indications for celiotomy?

Penetrating Trauma

Hypotension

Peritoneal / retroperitoneal injury

Peritonitis

Evisceration

+ DPL, FAST, or contrast CT


33/41

Remember

a missed abdominalinjury is a common

cause of a potentially

preventable death.


34/41

Pelvic Fractures

Mechanism

AP compression

Lateral

compression

Vertical shear


35/41

Pelvic Fractures

Classification

Open

Closed


36/41

Pelvic Fractures

Significant force

appliedAssociated

injuries

Pelvic bleeding Bone ends

Pelvic muscles Veins / arteries


37/41

Pelvic Fractures

Assessment

Inspection

Palpate prostate

Pelvic ring

Leg-length discrepancy, external rotation

Pain on palpation of bony pelvic ring


38/41

Pelvic Fractures

Fluid resuscitationDetermine if open or closed fracture

Determine associated perineal / GU injuries

Determine need for transfer

Splint pelvic fracture

Emergency Management


39/41


40/41


41/41

ABCDEs and early surgical consultation

Evaluation and management vary with a

mechanism and physiologic response

Repeated exams and diagnostic studies

High index of suspicion

Early recognition / prompt celiotomy

chapter 5, abdominal trauma

Documents