Evaluation Blunt Abdominal Trauma

7/29/2019 Evaluation Blunt Abdominal Trauma

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Trauma ConferenceTrauma Conference

January 9January 9thth, 2006, 2006

Greg Feldman, MDGreg Feldman, MDPGY1, General Surgery DepartmentPGY1, General Surgery Department

Stanford Medical CenterStanford Medical Center

Blunt Abdominal Trauma:Blunt Abdominal Trauma:

EvaluationEvaluation


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OutlineOutline

!! Anatomic definition of abdomenAnatomic definition of abdomen

!! Mechanisms of injury in blunt traumaMechanisms of injury in blunt trauma

!! Typical injury patternsTypical injury patterns

!! Assessment of blunt abdominal traumaAssessment of blunt abdominal trauma

!! Diagnostic algorithmsDiagnostic algorithms


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Abdomen: anatomic boundariesAbdomen: anatomic boundaries

!! External:External:!! Anterior abdomen:Anterior abdomen: transnippletransnipple line superiorly, inguinal ligaments andline superiorly, inguinal ligaments and

symphasissymphasis pubis inferiorly, anteriorpubis inferiorly, anterioraxillaryaxillary lines laterally.lines laterally.

!! Flank: between anterior and posteriorFlank: between anterior and posterioraxillaryaxillary lines from 6th intercostalslines from 6th intercostalsspace to iliac crest.space to iliac crest.

!!

Back: Posterior to posteriorBack: Posterior to posterioraxillaryaxillary lines, from tip of scapulae to iliac crests.lines, from tip of scapulae to iliac crests.!! Internal:Internal:

!! Upper peritoneal cavity: covered by lower aspect of bony thorax. IncludesUpper peritoneal cavity: covered by lower aspect of bony thorax. Includesdiaphragm, liver, spleen, stomach, transverse colon.diaphragm, liver, spleen, stomach, transverse colon.

!! Lower peritoneal cavity: small bowel, ascending and descending colon,Lower peritoneal cavity: small bowel, ascending and descending colon,sigmoid colon, and (in women) internal reproductive organs.sigmoid colon, and (in women) internal reproductive organs.

!! Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women)Pelvic cavity: contains rectum, bladder, iliac vessels, and (in women)internal reproductive organs.internal reproductive organs.

!! Retroperitoneal space: posterior to peritoneal lining of abdomen. AbdominalRetroperitoneal space: posterior to peritoneal lining of abdomen. Abdominalaorta, IVC, most of duodenum, pancreas kidneys,aorta, IVC, most of duodenum, pancreas kidneys, uretersureters, and posterior, and posterioraspects of ascending and descending colon.aspects of ascending and descending colon.


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Mechanisms of injuryMechanisms of injury

!! CCompression, crush, or sheer injury to abdominal visceraompression, crush, or sheer injury to abdominal viscera ""

deformation of solid or hollow organs, rupture (e.g. smalldeformation of solid or hollow organs, rupture (e.g. small

bowel, gravid uterus)bowel, gravid uterus)

!!

Deceleration injuries: differential movements of fixed andDeceleration injuries: differential movements of fixed andnonfixednonfixed structures (e.g. liver and spleenstructures (e.g. liver and spleen lacslacs at sites ofat sites of

supporting ligaments)supporting ligaments)


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Common injury patternsCommon injury patterns

!! In patients undergoingIn patients undergoing laparotomylaparotomy for blunt trauma, most frequentlyfor blunt trauma, most frequentlyinjured organs are spleen (40-55%), liver (35-45%), and small bowel (5-injured organs are spleen (40-55%), liver (35-45%), and small bowel (5-10%). (ATLS, 2001)10%). (ATLS, 2001)

!! Duodenum:Duodenum:

!!

Classically, frontal-impact MVC with unrestrained driver; or direct blow toClassically, frontal-impact MVC with unrestrained driver; or direct blow toabdomen.abdomen.

!! Bloody gastric aspirate, retroperitoneal air on XR or CTBloody gastric aspirate, retroperitoneal air on XR or CT

!! Confirmed with upper GI series or double contrast CTConfirmed with upper GI series or double contrast CT

!! Small bowel injury:Small bowel injury:

!! Generally from sudden deceleration with subsequent tearing near fixedGenerally from sudden deceleration with subsequent tearing near fixedpoints of attachment.points of attachment.

!! Often associated with seat belt sign, lumbar distraction fracture (ChanceOften associated with seat belt sign, lumbar distraction fracture (Chancefracture)fracture)

!! DPL superior to FAST or CT for diagnosis.DPL superior to FAST or CT for diagnosis.


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Common injury patterns (2)Common injury patterns (2)

!! Pancreas:Pancreas:!! DirectDirect epigastricepigastric blow compressing pancreas against vertebral column.blow compressing pancreas against vertebral column.

!! Early normal serum amylase does NOT exclude major pancreatic trauma.Early normal serum amylase does NOT exclude major pancreatic trauma.

!! CT with PO/IV contrastCT with PO/IV contrastNOT particularly sensitive in immediate post-NOT particularly sensitive in immediate post-injury period.injury period.

!! Diaphragm:Diaphragm:!! Most commonly, 5-10 cm rupture involvingMost commonly, 5-10 cm rupture involvingposterolateralposterolateral hemidiaphragmhemidiaphragm..

!! Noted on CXR: blurred or elevatedNoted on CXR: blurred or elevated hemidiaphragmhemidiaphragm,, hemothoraxhemothorax, GT in, GT inchestchest

!! Genitourinary:Genitourinary:

!! Anterior injuries (below UG diaphragm): usually from straddle impact.Anterior injuries (below UG diaphragm): usually from straddle impact.!! Posterior injuries (above UG diaphragm): in patient withPosterior injuries (above UG diaphragm): in patient with multisystemmultisystem

injuries and pelvic fractures.injuries and pelvic fractures.


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Common injury patterns (3)Common injury patterns (3)

!! Solid organ injurySolid organ injury

!! Laceration to liver, spleen, or kidneyLaceration to liver, spleen, or kidney

!! Injury to one of these three +Injury to one of these three + hemodynamichemodynamic instability: consideredinstability: consideredindication for urgentindication for urgent laparotomylaparotomy

!! Isolated solid organ injury inIsolated solid organ injury in hemodynamicallyhemodynamically stable patient: canstable patient: canoften be managedoften be managed nonoperativelynonoperatively..

!! Pelvic fractures:Pelvic fractures:

!! Suggest major force applied to patient.Suggest major force applied to patient.

!! Usually auto-Usually auto-pedped, MVC, or motorcycle, MVC, or motorcycle

!! Significant association withSignificant association with intraperitonealintraperitoneal and retroperitonealand retroperitonealorgans and vascular structures.organs and vascular structures.


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Restraining devicesRestraining devices

!! Lap seat beltLap seat belt!! Mesenteric tear or avulsionMesenteric tear or avulsion

!! Rupture of small bowel or colonRupture of small bowel or colon

!! Iliac artery or abdominal aorta thrombosisIliac artery or abdominal aorta thrombosis

!! Chance fracture of lumbar vertebrae (Chance fracture of lumbar vertebrae (hyperflexionhyperflexion))

!!Shoulder HarnessShoulder Harness!! Rupture of upper abdominal visceraRupture of upper abdominal viscera!! IntimalIntimal tear or thrombosis intear or thrombosis in innominateinnominate, carotid,, carotid, subclaviansubclavian, or vertebral arteries, or vertebral arteries

!! Fracture or dislocation of C-spineFracture or dislocation of C-spine

!! Rib fracturesRib fractures

!! Pulmonary contusionPulmonary contusion

!! Air BagAir Bag!! Corneal abrasions,Corneal abrasions, keratitiskeratitis

!! Abrasions of face, neck, chestAbrasions of face, neck, chest!! Cardiac ruptureCardiac rupture

!! C or T-spine fractureC or T-spine fracture


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Assessment: HistoryAssessment: History

!! MechanismMechanism

!! Symptoms, events, PMH, Meds,Symptoms, events, PMH, Meds, EtOHEtOH/drugs/drugs

!! MVC:MVC:

!! SpeedSpeed

!! Type of collision (frontal, lateral, sideswipe, rear,Type of collision (frontal, lateral, sideswipe, rear,rollover)rollover)

!! Vehicle intrusion into passenger compartmentVehicle intrusion into passenger compartment

!! Types of restraintsTypes of restraints

!! Deployment of air bagDeployment of air bag

!! Patient's position in vehiclePatient's position in vehicle


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Assessment: Physical ExamAssessment: Physical Exam

!! Inspection, auscultation, percussion, palpationInspection, auscultation, percussion, palpation

!! Inspection: abrasions, contusions, lacerations, deformityInspection: abrasions, contusions, lacerations, deformity

!! Grey-Turner,Grey-Turner, KehrKehr, Balance, Cullen, Balance, Cullen

!! Auscultation: careful exam advised by ATLS.Auscultation: careful exam advised by ATLS.(Controversial utility in trauma setting.)(Controversial utility in trauma setting.)

!! Percussion: subtle signs of peritonitis;Percussion: subtle signs of peritonitis; tympanytympany in gastricin gastric

dilatation or free air; dullness withdilatation or free air; dullness with hemoperitoneumhemoperitoneum

!! Palpation: elicit superficial, deep, or rebound tenderness;Palpation: elicit superficial, deep, or rebound tenderness;

involuntary muscle guardinginvoluntary muscle guarding


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Physical Exam: EponymsPhysical Exam: Eponyms

!! Grey-Turner sign:Grey-Turner sign:

!! Bluish discoloration of lower flanks, lower back; associated withBluish discoloration of lower flanks, lower back; associated withretroperitoneal bleeding of pancreas, kidney, or pelvic fracture.retroperitoneal bleeding of pancreas, kidney, or pelvic fracture.

!! Cullen sign:Cullen sign:

!! Bluish discoloration around umbilicus, indicates peritoneal bleeding,Bluish discoloration around umbilicus, indicates peritoneal bleeding,often pancreatic hemorrhage.often pancreatic hemorrhage.

!! KehrKehrsign:sign:

!! L shoulder pain while supine; caused by diaphragmatic irritationL shoulder pain while supine; caused by diaphragmatic irritation((splenicsplenic injury, free air, intra-injury, free air, intra-abdabd bleeding)bleeding)

!!

Balance sign:Balance sign:!! Dull percussion in LUQ. Sign ofDull percussion in LUQ. Sign ofsplenicsplenic injury; blood accumulatinginjury; blood accumulatinginin subcapsularsubcapsularororextracapsularextracapsularspleen.spleen.


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Diagnostic adjunctsDiagnostic adjuncts

!! Labs: BMP, CBC,Labs: BMP, CBC, coagscoags, b-HCG,, b-HCG, amyamy/lip, U/A,/lip, U/A, toxtox screen,screen,

T&CT&C

!! Plain films: CXR, pelvis;Plain films: CXR, pelvis; abdabd films generally lower priorityfilms generally lower priority

!! DPLDPL!! FASTFAST

!! CTCT


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Diagnostic PeritonealDiagnostic Peritoneal LavageLavage

!! 98% sensitive for98% sensitive forintraperitonealintraperitoneal bleeding (ATLS)bleeding (ATLS)

!! Open or closed (Open or closed (SeldingerSeldinger); usually); usually infraumbilicalinfraumbilical, but may be, but may besupraumbilicalsupraumbilical in pelvicin pelvic frxsfrxs or advanced pregnancy.or advanced pregnancy.

!! Free aspiration of blood, GI contents, or bile inFree aspiration of blood, GI contents, or bile in demodynamicallydemodynamicallyabnormal pt: indication forabnormal pt: indication forlaparotomylaparotomy

!! If gross blood (> 10If gross blood (> 10 mLmL) or GI contents not aspirated, perform) or GI contents not aspirated, perform lavagelavagewith 1000with 1000 mLmL warmed LR. Allow to mix, compress abdomen andwarmed LR. Allow to mix, compress abdomen andlogrosslogross paientpaient, the sent to lab. + test: >100,000 RBC/mm3, >500, the sent to lab. + test: >100,000 RBC/mm3, >500WBC/mm3, Gram stain with bacteria.WBC/mm3, Gram stain with bacteria.

!! Alters subsequent examination of patientAlters subsequent examination of patient

!! Has been somewhat superceded by FAST in common use; now generallyHas been somewhat superceded by FAST in common use; now generally

performed in unstable patients with intermediate FAST exams, or withperformed in unstable patients with intermediate FAST exams, or withsuspicion for small bowel injury.suspicion for small bowel injury.


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FAST: Strengths and LimitationsFAST: Strengths and Limitations

StrengthsStrengths

!! Rapid (~2Rapid (~2 minsmins))

!! PortablePortable

!! InexpensiveInexpensive

!! Technically simple, easy to trainTechnically simple, easy to train(studies show competence can be(studies show competence can beachieved after ~30 studies)achieved after ~30 studies)

!! Can be performed seriallyCan be performed serially!! Useful for guiding triage decisionsUseful for guiding triage decisions

in trauma patientsin trauma patients

LimitationsLimitations

!! Does not typically identify source ofDoes not typically identify source ofbleeding, or detect injuries that dobleeding, or detect injuries that donot causenot cause hemoperitoneumhemoperitoneum

!! Requires extensive training to assessRequires extensive training to assessparenchyma reliablyparenchyma reliably

!! Limited in detecting


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FAST: AccuracyFAST: Accuracy

For identifyingFor identifying hemoperitoneumhemoperitoneum in blunt abdominal trauma:in blunt abdominal trauma:

!! Sensitivity 76 - 90%Sensitivity 76 - 90%

!! Specificity 95 - 100%Specificity 95 - 100%

The larger theThe larger the hemoperitoneumhemoperitoneum, the higher the sensitivity. So, the higher the sensitivity. Sosensitivity increases forsensitivity increases forclinically significantclinically significanthemoperitoneumhemoperitoneum..

How much fluid can FAST detect?How much fluid can FAST detect?

!!250 cc total250 cc total

!! 100 cc in Morison100 cc in Morisons pouchs pouch


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Does FAST replace CT?Does FAST replace CT?

Only at the extremes.Only at the extremes.

!! Unstable patient, (+) FASTUnstable patient, (+) FAST "" OROR

!! Stable patient, low force injury, (-) FASTStable patient, low force injury, (-) FAST "" considerconsiderobserving patient.observing patient.

CT is far more sensitive than FAST for detecting andCT is far more sensitive than FAST for detecting andcharacterizing abdominal injury in trauma. The goldcharacterizing abdominal injury in trauma. The goldstandard for characterizingstandard for characterizing intraparenchymalintraparenchymal injury.injury.

Death begins with a CT.Death begins with a CT.

Never send an unstable patient toNever send an unstable patient to

CT. FAST, however, can be performed duringCT. FAST, however, can be performed duringresuscitation.resuscitation.


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CTCT

EAST level I recommendations (2001):EAST level I recommendations (2001):

!! CT is recommended for evaluation ofCT is recommended for evaluation ofhemodynamicallyhemodynamically

stable patients with equivocal findings on physicalstable patients with equivocal findings on physical

examination, associatedexamination, associated neurologicneurologic injury, or multipleinjury, or multiple

extra-abdominal injuries.extra-abdominal injuries.

!! CT is the diagnostic modality of choice forCT is the diagnostic modality of choice fornonoperativenonoperative

management of solid visceral injuries.management of solid visceral injuries.


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EAST Algorithm: UnstableEAST Algorithm: Unstable

Eastern Association for the Surgery of Trauma, 2001


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EAST Algorithm: StableEAST Algorithm: Stable

Eastern Association for the Surgery of Trauma, 2001


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ReferencesReferences

!! Hoff et al. EAST Practice Management Guidelines Work Group.Hoff et al. EAST Practice Management Guidelines Work Group.Practice Management Guidelines for the Evaluation of BluntPractice Management Guidelines for the Evaluation of BluntAbdominal Trauma, 2001.Abdominal Trauma, 2001. www.east.orgwww.east.org..

!! American College of Surgeons Committee on Trauma.American College of Surgeons Committee on Trauma.Advanced Trauma Life Support for Doctors; Student CourseAdvanced Trauma Life Support for Doctors; Student Course

Manual, 7Manual, 7thth edition, 2004.edition, 2004.!! ScaleaScalea TM, Rodriquez A, Chiu WC. Focused Assessment withTM, Rodriquez A, Chiu WC. Focused Assessment with

SonographySonography for Trauma (FAST): Results from an Internationalfor Trauma (FAST): Results from an InternationalConsensus Conference.Consensus Conference. J. TraumaJ. Trauma 1999;46:466-472.1999;46:466-472.

!! Yoshii H, Sato M, Yamamoto S. Usefulness and Limitations ofYoshii H, Sato M, Yamamoto S. Usefulness and Limitations ofUltrasonographyUltrasonography in the Initial Evaluation of Blunt Abdominalin the Initial Evaluation of Blunt Abdominal

Trauma.Trauma. J. TraumaJ. Trauma 1998;45:45-51.1998;45:45-51.


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AcknowledgementsAcknowledgements

!! Dr. ShellyDr. Shelly ErfordErford

!! Dr. Denny JenkinsDr. Denny Jenkins

!! Carol ThomsonCarol Thomson

!! Dr. NatalieDr. Natalie KirilchikKirilchik

!! Dr.Dr. SubarnaSubarna BiswasBiswas

!! Drs.Drs. BrundageBrundage, Spain, and Gregg, Spain, and Gregg

!! Stanford Medical Center ACS/Trauma ServiceStanford Medical Center ACS/Trauma Service

!! Noah FeinsteinNoah Feinstein

!! Dr. Gillian LiebermanDr. Gillian Lieberman

!! Dr. Jason TracyDr. Jason Tracy

Documents

Evaluation Blunt Abdominal Trauma