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Blunt abdominal trauma

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    Blunt abdominal trauma Blunt abdominal trauma Presentation Transcript

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