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Trauma– Blunt Abdominal Trauma. Douglas M. Maurer, DO, MPH. Learning Objectives. Recognize and respond appropriately to a patient with hemorrhagic shock Assess via bedside methods the source of hemorrhage - PowerPoint PPT Presentation
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Trauma– Blunt Abdominal Trauma
Douglas M. Maurer, DO, MPH
Learning Objectives
• Recognize and respond appropriately to a patient with hemorrhagic shock
• Assess via bedside methods the source of hemorrhage
• Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition
Introduction
• Blunt abdominal trauma is common. • Unknown history, distracting injuries, and
altered mental status make these patients difficult to diagnose and manage.
• Victims frequently have both abdominal and extraabdominal injuries.
• Family physicians need to be able to recognize and treat hemorrhagic shock.
Recognition of Hemorrhagic Shock
• Shock: oxygen delivery < tissue demands• Treatment must restore tissue perfusion not just
blood pressure• Shock does NOT SBP < 90mmHg• Recognition includes: mechanism of injury,
patient’s appearance, vitals, level of mentation, peripheral perfusion and urine output
• Clinical parameters should be coupled with objective markers of tissue perfusion--serum lactate, base deficit, etc.
Practical Diagnosis of Shock
• Perform a targeted physical examination • Diagnostic testing should include chest
radiography, pelvis radiography, and bedside ultrasound
• Objective serum makers of tissue perfusion (serum lactate or base deficit)
• Point of care H/H, send CBC, type/cross• DON’T delay resuscitation for lab results
6 Steps to Treat Hemorrhagic Shock
• Step 1: Effectively manage the airway and optimize oxygenation.
• Step 2: Identify and control immediate threats to central perfusion.
• Step 3: Identify and address severe intracranial injuries. • Step 4: Identify and control other potentially life-
threatening thoracic and abdominal injuries. • Step 5: Identify and control potentially limb-threatening
injuries. • Step 6: Identify and treat noncritical injuries.
Treatment of Hemorrhagic Shock
• Obtain immediate type and crossmatch for 6-8 units of blood
• Massive transfusion defined as > 10 U of PRBCs in 24 hrs
• Consider use of PRBC to platelet to FFP ratio of 1:1:1 • May result in decreased need for blood
products• Give calcium to prevent citrate toxicity
Assessing for Sources of Hemorrhage• Chest radiography:
• Tension pneumothorax? Massive hemothorax? Aortic injury?
• Pelvis radiography:• Pelvic ring disruption?
• Focused Assessment with Sonography for Trauma (FAST):• Pneumo/hemothorax? Hemopericardium? Hemoperitoneum?• If positive, then emergency laparotomy.• If negative, continue resuscitation, treat other causes.
FAST Facts
• Reliably identifies 200-250ml of intraperitoneal fluid
• Cannot reliably evaluate retroperitoneum/hollow viscous injury
• Sensitivity/specificity: 75%/98%, NPV: 94%; 86-97% accurate
• Performed using a curvilinear 2.5 or 3.5 MHz probe
FAST Views
• Cardiac: parasternal or subxiphoid, hepatocardiac interface, pericardial space.
• RUQ: hepatorenal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney.
• LUQ: splenorenal interface, diaphragm, inferior pole of kidney, inferior tip of spleen.
• Suprapubic: outline of bladder, silhouette of uterus (females).
FAST Algorithm
• Unstable patient: + FAST = OR.• Stable pt: + FAST = abdominal CT.• Stable pt, low mechanism of injury:
- FAST = observation, serial exams.• CT is the “Gold Standard”.
What About Diagnostic Peritoneal Aspiration (DPA)?
• Can be performed if - FAST in blunt abdominal trauma.
• If DPA +, then emergency laparotomy.• If DPA -, then seek and treat other sources.
• Perform serial abdominal exams.• Perform serial FAST exams.• If patient stabilizes, then CT.
• Get surgery involved!
Indications for Emergency Laparotomy
• Peritonism• Free air under the diaphragm• Significant gastrointestinal hemorrhage• Hypotension with + FAST scan or + DPA • Do NOT keep trauma patients if you lack
resources to care for them!
Summary
• Recognize and treat hemorrhagic shock aggressively with blood products
• Assess for hemorrhage with bedside methods: CXR, pelvis, and FAST
• Unstable patient: + FAST = OR.• Stable pt: + FAST = abdominal CT.• Stable pt, low mechanism of injury:
- FAST = observation, serial exams.
References
1. Puskarich MA. Initial evaluation and management of blunt abdominal trauma in adults. In: UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012.
2. Nickson C. “Trauma! Blunt abdominal trauma decision making.” Weblog entry. Life in the Fastlane Blog. http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/
3. Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma. 2010 Edition. Chicago, IL. http://www.east.org/resources/treatment-guidelines/category/trauma
4. American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.
Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma
Douglas M. Maurer, DO, MPH, FAAFP
CRITICAL ACTIONS ME NI M SUSTAIN IMPROVE
Completes Primary Survey: recognizes shock
MK2
Safety net – IV, oxygen, monitors (2 x 16G IV)
MK2
Completes Secondary Survey: recognizes abdominal source
MK2
Completes bedside FAST(+ Morrison’s Pouch)
PC5
Recognizes positive FAST: calls surgery
PC5
Bedside labs: POC CBC, lactate, BAL, VBG, blood type/screen/X-match
MK2
Bedside rads: port chest, lat C-spine, AP pelvis
MK2
Gives emergency release blood transfusion
MK2
If unstable: no CT, to ORIf stabilizes: CT, then OR
MK2
TOTAL SBP4
SCENARIO ALGORITHM
SET UP:“Rural” ER Simulated Room
Bedside US and/or FAST simulatorReal patient with simulated skin/abdomen
PRE ARRIVAL:FP in rural ER, lab, rad, OR
35 y/o male s/p unrestrained driver MVA arrives via EMS, in c-collar. VS BP 90/50, HR
110, RR 18, SpO2 97% on RA, GCS 15
ARRIVAL:Full spinal precautions, has 1 IV in place. Pt
awake, alert, conversing, but in mild distress, no meds, no allergies, no sig PMHx or PSHx
PRIMARY SURVEY:A – talking initially, then somnolent B – labored, RR 24, nl breath sounds
C – BP 85/40, HR 130, cool extremitiesD – GCS 14, somnolent, oriented to person
when responds to voiceE – no other trauma, mild abd distension,
hypoactive BS
SECONDARY SURVEY:Other exam normal, c-spine non tender,
pelvis stable, rectal guaiac negativeAbdominal exam tense, tender, absent BS
LABS & IMAGES:Chest, c-spine, pelvis negative
Labs – WBC 9, H/H 8/24, platelets 150, lactate 4, VBG: 7.35/46/40/50%/-8
Positive FAST in RUQ, no CT indicatedBlood type and screen/X-match
DISPOSITION:Must transfuse blood , call Surgeon and direct
to OR, otherwise pt dies of hemorrhage
Simulation Training Assessment Tool (STAT)– Blunt Abdominal TraumaDate: 1 May 2013 Instructor(s): Clark, Maurer, Cuda Learner(s):
Learning Objectives:1. Recognize and respond appropriately to a patient with hemorrhagic shock.2. Assess via bedside methods the source of hemorrhage.3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition.
ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)
Perihepatic
Perihepatic
Perisplenic
Perisplenic
Pelvic
Pelvic
Pericardium
Pericardium