Blunt abdominal trauma

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Blunt abdominal trauma

  1. 1. Blunt Abdominal Trauma Jose David Gamez, MD.
  2. 2. Causes <ul><ul><li>Motor vehicle crashes </li></ul></ul><ul><ul><li>Auto-pedestrian injury </li></ul></ul><ul><ul><li>Falls </li></ul></ul><ul><ul><li>Bicycle injuries </li></ul></ul><ul><ul><li>All-terrain vehicle injuries </li></ul></ul><ul><ul><li>Child abuse </li></ul></ul>
  3. 3. Mortality <ul><ul><li>Less than 20% in isolated </li></ul></ul><ul><ul><li>20% in GI tract </li></ul></ul><ul><ul><li>50% with major vessels </li></ul></ul>Cantor RM, Leamin JM. Evaluation and management of pediatric major trauma. Emer Med Clin Noth Am 1998.
  4. 4. Anatomy <ul><ul><li>Compact torsos </li></ul></ul><ul><ul><li>Smaller AP diameters </li></ul></ul><ul><ul><li>Large viscera </li></ul></ul><ul><ul><li>Less overlying fat </li></ul></ul><ul><ul><li>Weaker abdominal musculature </li></ul></ul>
  5. 5. Evaluation <ul><ul><li>History information </li></ul></ul><ul><ul><li>Mechanism of injury </li></ul></ul><ul><ul><li>Physical examination </li></ul></ul>Moos RL, Musemeche CA. Clinical judgment is superior to diagnostic test in the management of pediatric small bowel injury. J pediatr Surg 1996.
  6. 6. Mechanism of injury <ul><ul><li>Lateral motor vehicle collisions </li></ul></ul><ul><ul><li>Seal belt usage </li></ul></ul><ul><ul><li>falls </li></ul></ul>
  7. 7. Physical Exam <ul><ul><li>Initial assessment </li></ul></ul><ul><ul><ul><li>Airway compromise </li></ul></ul></ul><ul><ul><ul><li>Respiratory mechanics </li></ul></ul></ul><ul><ul><ul><li>Hemorrhagic shock </li></ul></ul></ul><ul><ul><ul><li>Level of consciousness </li></ul></ul></ul><ul><ul><li>Secondary survey </li></ul></ul><ul><ul><ul><li>Head to toe examination </li></ul></ul></ul>
  8. 8. Abdomen <ul><ul><li>NG tube: gastric decompression </li></ul></ul><ul><ul><li>Serial examinations </li></ul></ul><ul><ul><li>Signs </li></ul></ul><ul><ul><ul><li>Ecchymoses </li></ul></ul></ul><ul><ul><ul><li>Abrasions </li></ul></ul></ul><ul><ul><ul><li>Tire-tracks </li></ul></ul></ul><ul><ul><ul><li>Seal-belt marks </li></ul></ul></ul><ul><ul><ul><li>Abdominal distention </li></ul></ul></ul><ul><ul><ul><li>Tenderness </li></ul></ul></ul><ul><ul><ul><li>Rigidity </li></ul></ul></ul><ul><ul><ul><li>Masses </li></ul></ul></ul><ul><ul><ul><li>Kehr’s sign </li></ul></ul></ul><ul><ul><ul><li>Prolonged ileus </li></ul></ul></ul><ul><ul><ul><li>Blood on rectal examination </li></ul></ul></ul>
  9. 9. Associated injuries <ul><ul><li>Rib fracture </li></ul></ul><ul><ul><ul><li>20 % splenic injury </li></ul></ul></ul><ul><ul><ul><li>10% hepatic injury </li></ul></ul></ul><ul><ul><li>Perineal laceration: pelvic fracture </li></ul></ul><ul><ul><li>Decreased rectal sphincter tone: spinal cord injury </li></ul></ul><ul><ul><ul><li>Priapism </li></ul></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Decreased strength </li></ul></ul></ul><ul><ul><ul><li>Decreased sensation </li></ul></ul></ul>
  10. 10. Laboratory Evaluation <ul><ul><li>CBC </li></ul></ul><ul><ul><li>Type and cross </li></ul></ul><ul><ul><li>UA </li></ul></ul><ul><ul><li>Transaminases </li></ul></ul><ul><ul><li>Amylase </li></ul></ul>Taylor GA et al. Hematuria. A marker of abdominal injury in children after blunt trauma. Ann Surg 1988
  11. 11. Laboratory Evaluation <ul><ul><li>Prospective observational </li></ul></ul><ul><ul><li>Younger than 16 years </li></ul></ul><ul><ul><li>Level I trauma center in Sacramento, CA </li></ul></ul><ul><ul><li>1095 patients </li></ul></ul><ul><ul><li>107 intraabdominal injuries </li></ul></ul><ul><ul><li>Findings associated: </li></ul></ul><ul><ul><ul><li>Low systolic BP </li></ul></ul></ul><ul><ul><ul><li>Abdominal tenderness </li></ul></ul></ul><ul><ul><ul><li>Femur fracture </li></ul></ul></ul><ul><ul><ul><li>AST>200 or ALT>125 </li></ul></ul></ul><ul><ul><ul><li>UA with >5 RBC </li></ul></ul></ul><ul><ul><ul><li>Initial hematocrit < 30% </li></ul></ul></ul>Holmes et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002.
  12. 12. Radiologic Evaluation <ul><ul><li>X Ray </li></ul></ul><ul><ul><ul><li>Elevated hemi diaphragm </li></ul></ul></ul><ul><ul><ul><li>Displaced gastric bubble </li></ul></ul></ul><ul><ul><ul><li>Free abdominal gas </li></ul></ul></ul>
  13. 13. Radiologic Evaluation: CT <ul><ul><li>Sensitive and specific </li></ul></ul><ul><ul><ul><li>Liver </li></ul></ul></ul><ul><ul><ul><li>Spleen </li></ul></ul></ul><ul><ul><ul><li>Retroperitoneal injuries </li></ul></ul></ul><ul><ul><li>Less sensitive </li></ul></ul><ul><ul><ul><li>Pancreas </li></ul></ul></ul><ul><ul><ul><li>Intestinal tract </li></ul></ul></ul><ul><ul><ul><li>Bladder </li></ul></ul></ul><ul><ul><ul><li>Lumbar spine </li></ul></ul></ul>
  14. 14. Indications CT scan <ul><ul><li>Injury suggestive of intraabdominal trauma </li></ul></ul><ul><ul><li>AST>450 IU/L and ALT>250 IU/L </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Declining hematocrit </li></ul></ul><ul><ul><li>Unaccountable fluid o blood requirements </li></ul></ul><ul><ul><li>Inability to perform adequate examination </li></ul></ul>Rothrock et al. Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Pediatr Emerg Care 2000.
  15. 15. Radiologic Evaluation: US <ul><ul><li>Detection of intraperitoneal fluid. </li></ul></ul><ul><ul><ul><li>Bedside </li></ul></ul></ul><ul><ul><ul><li>Rapid </li></ul></ul></ul><ul><ul><ul><li>No adverse effects </li></ul></ul></ul><ul><ul><ul><li>Inaccurate to detect hollow viscus injury </li></ul></ul></ul><ul><ul><ul><li>Poor image quality in the presence of bowel gas o fat </li></ul></ul></ul><ul><ul><ul><li>Sonographer dependent </li></ul></ul></ul><ul><ul><ul><li>Low sensitivity </li></ul></ul></ul>
  16. 16. Peritoneal lavage <ul><ul><li>Less injury and organ-specific </li></ul></ul><ul><ul><li>Cannot detect retroperitoneal injury </li></ul></ul><ul><ul><li>Risks: </li></ul></ul><ul><ul><ul><li>Introduction of air or fluid into the abdomen </li></ul></ul></ul><ul><ul><ul><li>Peritoneal irritation </li></ul></ul></ul><ul><ul><ul><li>oversensitivity </li></ul></ul></ul>
  17. 17. Peritoneal lavage <ul><ul><li>Positive: </li></ul></ul><ul><ul><ul><li>More than 5 ml of gross blood </li></ul></ul></ul><ul><ul><ul><li>Bile or stool obtained </li></ul></ul></ul><ul><ul><ul><li>Extravasation of fluid from chest tube or bladder catheter </li></ul></ul></ul><ul><ul><ul><li>Lavage fluid with >100,000 RBC or >500 WBC/mm 3 </li></ul></ul></ul>
  18. 18. Spleen <ul><ul><li>Most common organ injured </li></ul></ul><ul><ul><li>Hemorrhagic shock </li></ul></ul><ul><ul><li>Diffuse abdominal tenderness </li></ul></ul><ul><ul><li>LUQ pain </li></ul></ul><ul><ul><li>Left shoulder pain </li></ul></ul>
  19. 19. Spleen <ul><ul><li>Delayed presentation </li></ul></ul><ul><ul><ul><li>Left subcostal pain </li></ul></ul></ul><ul><ul><ul><li>Left shoulder pain </li></ul></ul></ul><ul><ul><ul><li>Jaundice </li></ul></ul></ul><ul><ul><ul><li>Abdominal distention </li></ul></ul></ul><ul><ul><ul><li>Rigidity </li></ul></ul></ul><ul><ul><ul><li>Rebound </li></ul></ul></ul><ul><ul><ul><li>Anemia </li></ul></ul></ul>
  20. 20. Splenic laceration classification GRADE TYPE FINDINGS I Hematoma Subcapsular, < 10% surface area Laceration Capsular tear, < 1cm parenchymal depth II Hematoma Subcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter Laceration 1-3cm parenchymal depth; trabecular vessels not involved III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm or expanding Laceration >3cm parenchymal depth or involving trabecular vessels IV Laceration Involves segmental or hilar vessels producing major devascularization (>25% of spleen) V Laceration Completely shattered spleen Vascular Hilar vascular injury that devascularizes spleen Moore et al. Organ injury scaling: spleen and liver. J Trauma 1995
  21. 21. Grade I Hematoma Subcapsular, < 10% surface area Laceration Capsular tear, < 1cm parenchymal depth
  22. 22. Grade II Hematoma Subcapsular, 10-50% surface area; intraparenchymal, <5cm in diameter Laceration 1-3cm parenchymal depth; trabecular vessels not involved
  23. 23. Grade III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >5 cm or expanding Laceration >3cm parenchymal depth or involving trabecular vessels
  24. 24. Grade IV Laceration Involves segmental or hilar vessels producing major devascularization (>25% of spleen)
  25. 25. Grade V Laceration Completely shattered spleen Vascular Hilar vascular injury that devascularizes spleen
  26. 26. Guidelines <ul><ul><li>856 children </li></ul></ul><ul><ul><li>32 pediatric surgical centers </li></ul></ul><ul><ul><li>July 1995 to June 1997 </li></ul></ul><ul><ul><li>Isolated grade IV: observation 1 day in PICU and in hospital 5 days </li></ul></ul><ul><ul><li>Hospital stay for grade I-III: grade + 1 (day) </li></ul></ul><ul><ul><li>Activities restriction: grade + 2 (weeks) </li></ul></ul>Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury. The APSA Trauma Commite. J Pediatr Surg. 2000
  27. 27. Guidelines <ul><ul><li>312 children </li></ul></ul><ul><ul><li>16 centers </li></ul></ul><ul><ul><li>1998 to 2000 </li></ul></ul><ul><ul><li>Reduction in ICU and hospital stay </li></ul></ul><ul><ul><li>Better patient management </li></ul></ul><ul><ul><li>Improved utilization of resources </li></ul></ul><ul><ul><li>Validation of guidelines </li></ul></ul><ul><li>Evidence-based guidelines for children with isolated spleen or liver injury. Canadian AGS-EBRS. J Can Chir. December 2004 </li></ul>
  28. 28. Liver <ul><ul><li>Larger and less fibrous stroma, more susceptible to laceration and bleeding </li></ul></ul><ul><ul><li>2 nd most common injured organ </li></ul></ul><ul><ul><li>More severe than splenic injury </li></ul></ul><ul><ul><li>Most common fatal abdominal injury </li></ul></ul><ul><ul><li>Mortality 10-20% </li></ul></ul>
  29. 29. Hemobilia <ul><ul><li>Bleeding from hepatobiliary tract </li></ul></ul><ul><ul><li>Classic triad: </li></ul></ul><ul><ul><ul><li>Biliary colic </li></ul></ul></ul><ul><ul><ul><li>Obstructive jaundice </li></ul></ul></ul><ul><ul><ul><li>Occult or acute GI bleeding </li></ul></ul></ul><ul><ul><li>Diagnosis: Cholangiography </li></ul></ul>
  30. 30. Pancreas <ul><ul><li>Less than 3% </li></ul></ul><ul><ul><li>Mechanism: </li></ul></ul><ul><ul><ul><li>Bicycle handlebars </li></ul></ul></ul><ul><ul><ul><li>Motor vehicle crashes </li></ul></ul></ul><ul><ul><ul><li>Child abuse </li></ul></ul></ul><ul><ul><li>Signs: </li></ul></ul><ul><ul><ul><li>Vomiting </li></ul></ul></ul><ul><ul><ul><li>Abdominal pain radiated to the back </li></ul></ul></ul><ul><ul><ul><li>Epigastric tenderness </li></ul></ul></ul><ul><ul><ul><li>Peritonitis </li></ul></ul></ul><ul><ul><ul><li>Hypovolemia </li></ul></ul></ul>
  31. 31. Pancreas <ul><ul><li>Delayed presentation: </li></ul></ul><ul><ul><ul><li>Pancreatic pseudocyst </li></ul></ul></ul><ul><ul><ul><li>Epigastric pain </li></ul></ul></ul><ul><ul><ul><li>Palpable abdominal mass </li></ul></ul></ul><ul><ul><ul><li>Hyperamylasemia </li></ul></ul></ul>
  32. 32. GI tract <ul><ul><li>1-15% </li></ul></ul><ul><ul><li>Mechanism: </li></ul></ul><ul><ul><ul><li>Motor vehicle </li></ul></ul></ul><ul><ul><ul><li>Bicycle related </li></ul></ul></ul><ul><ul><ul><li>Child abuse </li></ul></ul></ul>
  33. 33. Perforation <ul><ul><li>Most common intestinal injury </li></ul></ul><ul><ul><li>Jejunum>ileum>duodenum </li></ul></ul><ul><ul><li>Bruising abdominal wall </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Abdominal X-Ray </li></ul></ul><ul><ul><ul><li>Free air </li></ul></ul></ul><ul><ul><ul><li>Scoliosis towards affected side </li></ul></ul></ul><ul><ul><ul><li>ileus </li></ul></ul></ul><ul><ul><li>CT </li></ul></ul><ul><ul><ul><li>Pneumoperitoneum </li></ul></ul></ul><ul><ul><ul><li>Free peritoneal fluid </li></ul></ul></ul>
  34. 34. Duodenal Hematoma <ul><ul><li>1-5 days after injury </li></ul></ul><ul><ul><li>Gastric distention </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Bilious vomiting </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Upper abdominal mass </li></ul></ul><ul><ul><li>X-Ray nonspecific </li></ul></ul><ul><ul><li>Abdominal US </li></ul></ul><ul><ul><li>CT </li></ul></ul>
  35. 35. Seat belt syndrome <ul><ul><li>Abdominal wall contusions </li></ul></ul><ul><ul><li>GI tract perforation </li></ul></ul><ul><ul><li>Lumbar spine injuries </li></ul></ul><ul><ul><li>Abdominal aortic injury </li></ul></ul><ul><ul><li>5-9 years old </li></ul></ul><ul><ul><li>Serial exams </li></ul></ul>
  36. 36. Management <ul><ul><li>ABC </li></ul></ul><ul><ul><li>Vascular acces </li></ul></ul><ul><ul><li>Warm IV solutions </li></ul></ul><ul><ul><li>Bladder catheterization </li></ul></ul><ul><ul><ul><li>Gross hematuria </li></ul></ul></ul><ul><ul><ul><li>Blood in urethral meatus </li></ul></ul></ul><ul><ul><ul><li>Scrotal hematoma </li></ul></ul></ul><ul><ul><ul><li>Perineal hematoma </li></ul></ul></ul>
  37. 37. Laparotomy <ul><ul><li>Persistent o recurrent hemodynamic instability </li></ul></ul><ul><ul><li>Penetrating abdominal wound </li></ul></ul><ul><ul><li>Pneumoperitoneum </li></ul></ul><ul><ul><li>Abdominal distention and hypotension </li></ul></ul>

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