Emergency lectures - Abd trauma vietnam


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  • 5-1 Title Slide Introduce the topic and explain to the students that, based on their preparation for the course, student participation and responses are expected. Photograph of seatbelt injury courtesy of John Fildes, MD, FACS
  • 5-3 Objectives Review the objectives as provided on the slide. Emphasize the clinical and other important aspects of the approach to the injured patient with abdominal trauma.
  • 5-4 External Anatomy This slide illustrates the three main areas of external abdominal anatomy. Briefly review each component while relating the potential structures for injury that exist within each. The anterior abdomen extends from the 4th intercostal space superiorly (often the transnipple line in men) to the inguinal ligament and symphysis pubis inferiorly, and between the anterior axillary lines. The flank area extends from the 6th intercostal space superior to the iliac wing inferiorly, and between the anterior and posterior axillary lines. The back area extends from the tip of the scapula superiorly to the iliac crest (or the inferior gluteal fold) inferiorly, and between the posterior axillary lines.
  • 5-5 Abdominal Injury: When should you suspect abdominal injury? Elicit responses from the students. Answers appear on next slide.
  • 5-6 Abdominal Injury: When should you suspect abdominal injury? The history and physical exam findings suggesting abdominal injury in blunt and penetrating trauma are listed.
  • 5-7 Abdominal Injury: Blunt Force Mechanism What organs are most commonly injured in blunt trauma? The most commonly injured intraabdominal organs in blunt trauma are: (1) spleen (40% to 55%), (2) liver (35% to 45%), and bowel (5% to 10%). As the students list the organs, ask them about the types of blunt force that cause the injuries: (1) compression: direct blow to liver or blowout of the bowel; (2) crushing: direct blow to the epigastrium with crushing of the pancreas over the spine; and (3) shearing: inappropriate location of the lap belt contributing to bowel injury. Airbag deployment does not preclude injury. Three-point restraints are better than the use of the lap belt only, and the lap belt is better than no restraint. Explain that solid organs bleed, but the patient may be nonoperatively managed (observed) if the bleeding is slow and spontaneously stops.
  • 5-8 Abdominal Injury: Penetrating Mechanism How does penetrating force injure? The radiograph is of a patient who presented with a single, small, round high-velocity rifle wound to the left upper quadrant. Three fragments (two large and one small) are seen at the diaphragm. Emphasize the difference between stab and gunshot wounds.
  • 5-9 Abdominal Injury: How do I determine if there is an abdominal injury? Elicit responses from the students. Answers appear on next slide.
  • 5-10 Abdominal Injury: How do I determine if there is an abdominal injury? Reveal the bulleted items after eliciting responses from the student. Physical exam should include inspection, auscultation, percussion, and palpation. After identifying “auscultation,” ask the students where to auscultate and what to listen for. The answer: all four quadrants for the presence or absence of bowel sounds. Explain that free intraperitoneal blood or gastrointestinal contents can produce an ileus. Caution the students that injuries to adjacent structures also can produce an ileus when an intraabdominal injury does not exist. After identifying “percussion,” ask the students about subtle signs of peritonitis, tympanitic sounds, and diffuse dullness. Obvious pain and involuntary guarding are indicative of rebound, and further maneuvers to elicit it (“Does it hurt worse when I push in or let off?”) are not necessary and only cause the patient undue discomfort. After the students identify “palpation,” ask them about the significance of involuntary muscle guarding, rebound tenderness, and the presence of a pregnant uterus.
  • 5-11 Abdominal Injury: Factors that compromise the exam During the discussion on assessment, ask the students what factors can compromise the abdominal examination. The students should respond with the bulleted items on the slide. You may ask the students, “How do associated orthopedic injuries compromise, limit, or distract from the abdominal examination?”
  • 5-12 Adjuncts: Gastric Tube Why is a gastric tube inserted for the patient with abdominal trauma? When and why do I need to be cautious when inserting a gastric tube?
  • 5-13 Adjunct: Urinary Catheter Why is a urinary catheter inserted in the patient with an abdominal injury? When and why do I need to exercise caution when inserting a urinary catheter? The illustration serves as a graphic reminder to assess for signs of a possible urethral injury before inserting a urinary catheter, such as perineal and scrotal hematomas, bleeding from the urethra, and rectal blood on the examiner’s gloved finger. Photograph courtesy of John A. Weigelt, MD, FACS, USA
  • 5-14 Adjuncts: Blood and Urine Tests Emphasize key points related to these items from the text, particularly that an urgent abdominal exploration should not be delayed for tests once the indication for surgery is discovered.
  • 5-15 Adjuncts: X-ray Studies What x-ray studies do I need to obtain on the patient who sustained blunt and penetrating abdominal trauma? Emphasize salient points from the text during the discussion, including differentiating tests done for the hemodynamically normal and abnormal patient with abdominal trauma. A normal chest radiograph and a pelvic x-ray showing widening of the pubic symphysis and a sacroiliac fracture are shown.
  • 5-16 Adjuncts: Contrast Studies What contrast studies should be obtained and what circumstances dictate whether to obtain them in the patient with abdominal injury? Emphasize salient points from the text during the discussion. Emphasize the need for speed to definitive care. CT scan of renal retroperitoneal hematoma courtesy of Trauma.org, renal 0005, http://trauma.org/imagebank/imagebank.html.
  • 5-17 Diagnostic studies: Blunt Trauma (Table 5-2)
  • 5-18 Diagnostic Studies: Penetrating Trauma—Hemodynamically Normal Note the different approaches for lower chest, anterior abdominal, and back/flank stab wounds. Describe the relative advantages and disadvantages of each.
  • Focused
  • 5-19 Explosions This patient was on his way to work when he was injured by an intentionally placed explosive device. He was thrown 15 feet, sustaining multiple penetrating fragments to the limbs, abdomen and chest. He was treated with ABC care. Evaluation showed a right pneumothorax from fragments and intraabdominal bleeding from penetrating fragments. Emphasize t he significance of a combination of mechanisms in blast injury, as well as the historical facts of the injury event.
  • 5-20 Laparotomy: Who requires a laparotomy? Elicit appropriate responses from the students.
  • 5-21 Laparotomy: Who requires a laparotomy?
  • 5-22 Laparotomy: Indications for Laparotomy – Blunt Trauma What are the indications for a laparotomy in the patient who sustained blunt abdominal trauma? The indications listed on this slide are commonly used to facilitate the surgeon’s decision-making process in this regard. Explain the role of FAST and the use of CT for non-operative management.
  • 5-23 Laparotomy: Indications for Laparotomy – Penetrating Trauma What are the indications for a laparotomy in the patient who sustained penetrating abdominal trauma? Explain that, in individual patients, surgical judgment is required to determine the timing and need for an operation. The indications listed on this slide are commonly used to facilitate the surgeon’s decision-making process in this regard. Explain the role of a positive FAST as confirmation of the abdomen as a source, as well as the potential for a negative FAST to be misleading, especially early. Emphasize the safe approach of early operation for patients with abdominal gunshot wounds.
  • 5-24 Pelvic Fractures A 45-year-old male was involved in a motorcycle crash at high speed. He had a pelvic fracture with disrupted bladder neck (as seen on the urethrography) and multiple intraabdominal injuries. A pelvic x-ray with extravasated urethral contrast is shown. Emphasize the association of pelvic fracture with significant abdominal injury, as well as the importance of the pelvis as a source of blood loss in hemorrhagic shock.
  • 5-25 Pelvic Fractures: Assessment of Pelvic Fractures Emphasize that manual manipulation of the pelvis to test for mechanical instability is performed only once (if at all) and in a step-wise fashion. If at any maneuver, instability is demonstrated, no subsequent maneuver is necessary. Repeated testing for pelvic instability can dislodge clots from coagulated vessels and result in fatal hemorrhage. Describe other physical exam findings, including leg length discrepancy. Explain the imperative of performing rectal and vaginal exams in patients with a known or suspected pelvic fracture.
  • 5-26 Pelvic Fractures: How do I manage patients with pelvic fractures? Elicit responses from the students. Answers appear on next slide.
  • 5-27 Pelvic Fractures: How do I manage patients with pelvic fractures? At the initial evaluation of the patient, a pelvic fracture may cause massive hemorrhage and should be considered with “C.” Efforts should be made to control hemorrhage with a pelvic wrap while early surgical consultation is obtained. Describe some of the possible methods of hemorrhage control beyond wrapping and binding.
  • 5-28 Pelvic Fractures: Hemodynamically Abnormal Patients This algorithm is included in the ATLS Student Manual. Use this slide to summarize the management of pelvic fractures. Emphasize the key points of obtaining surgical consultation, binding the pelvis, and determining if there is gross intraperitoneal blood. Ask the students how this can usually be determined (a grossly positive DPL [>10 mL]). The use of the FAST exam, if positive, may be helpful. Computed tomography is not indicated in the hemodynamically abnormal patient. Ask the students about transferring the patient. Their response should be affirmative if resources are not available. The students also should relate that orthopedic consultation is required. The key understanding is that hemorrhage must be controlled, and it may take a combination of methods to be successful.
  • 5-29 Pitfalls
  • 5-31 Summary Use these bulleted items to summarize the presentation. You may wish to expand on these items, reiterating relevant salient points from the presentation.
  • 5-2 Case Scenario The discussion of this case should emphasize the need to evaluate the abdomen first for hemorrhage quickly, and to discover other injuries that may lead to delayed mortality and morbidity. The patient is 35 years old and was involved in a high speed motor vehicle crash. Vital signs are: BP 105/80; P 110; RR 18; and GCS 15. He complains of pain in his chest, abdomen and pelvis. The discussion should dispense quickly with ABCs and move on to the abdominal evaluation. Elicit from the students the fact that, from the mechanism of injury, history, and inspection, there is likely an abdominal injury. Ask how they would begin to evaluate it.
  • 5-30 Questions Ask for questions from the students and then pause, allowing the students adequate time to form and ask their questions.
  • Emergency lectures - Abd trauma vietnam

    1. 1. Initial Assessment and Management Committee on Trauma Presents Abdominal and Pelvic Trauma
    2. 2. Objectives <ul><li>Identify key anatomical features of the abdomen. </li></ul><ul><li>Recognize patients at risk for abdominal and pelvic injuries based on the mechanism of injury. </li></ul><ul><li>Describe the evaluation of patients with suspected abdominal and pelvic injuries. </li></ul><ul><li>FAST exam with Ultrasound </li></ul><ul><li>Describe the acute management of abdominal and pelvic injuries. </li></ul>
    3. 3. External Anatomy of Abdomen
    4. 4. Abdominal Injury When should you suspect abdominal injury?
    5. 5. Abdominal Injury <ul><ul><li>Blunt </li></ul></ul><ul><ul><li>Speed </li></ul></ul><ul><ul><li>Point of impact </li></ul></ul><ul><ul><li>Intrusion </li></ul></ul><ul><ul><li>Safety devices </li></ul></ul><ul><ul><li>Position </li></ul></ul><ul><ul><li>Ejection </li></ul></ul>When should you suspect abdominal injury? <ul><ul><li>Penetrating </li></ul></ul><ul><ul><li>Weapon </li></ul></ul><ul><ul><li>Distance </li></ul></ul><ul><ul><li>Number and location of wounds </li></ul></ul>
    6. 6. Can you tell me <ul><li>What are the top 3 most commonly injured organs in the abdomen? </li></ul>
    7. 7. Abdominal Injury <ul><ul><li>Spleen </li></ul></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Small bowel </li></ul></ul>Blunt Force Mechanism Commonly Injured Organs
    8. 8. Abdominal Injury <ul><ul><li>Stab </li></ul></ul><ul><ul><ul><li>Low energy, lacerations </li></ul></ul></ul><ul><ul><li>Gunshot </li></ul></ul><ul><ul><ul><li>Kinetic energy transfer </li></ul></ul></ul><ul><ul><ul><ul><li>Cavitation, tumble </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fragments </li></ul></ul></ul></ul>Penetrating Mechanism Any Organ at Risk
    9. 9. Abdominal Injury How do I determine if there is an abdominal injury?
    10. 10. Abdominal Injury How do I determine if there is an abdominal injury? <ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Auscultation </li></ul></ul><ul><ul><li>Percussion </li></ul></ul><ul><ul><li>Palpation </li></ul></ul>Assessment: Physical Exam
    11. 11. Abdominal Injury A missed abdominal injury can cause a preventable death. Factors that Compromise the Exam <ul><ul><li>Alcohol and other drugs </li></ul></ul><ul><ul><li>Injury to brain, spinal cord </li></ul></ul><ul><ul><li>Injury to ribs, spine, pelvis </li></ul></ul>Caution
    12. 12. Adjuncts Basilar skull / facial fractures Can induce vomiting / aspiration <ul><ul><li>Relieves distention </li></ul></ul><ul><ul><li>Decompresses stomach before DPL </li></ul></ul>Gastric Tube Caution
    13. 13. Adjuncts <ul><ul><li>Monitors urinary output </li></ul></ul><ul><ul><li>Decompresses bladder before DPL </li></ul></ul><ul><ul><li>Diagnostic </li></ul></ul><ul><ul><li>If there is blood in meatus, do not place catheter </li></ul></ul>Urinary Catheter Caution
    14. 14. Adjuncts <ul><ul><li>No mandatory blood tests before urgent laparotomy </li></ul></ul><ul><ul><li>Hemodynamically abnormal: type and crossmatch, coagulation studies </li></ul></ul><ul><ul><li>Pregnancy testing </li></ul></ul><ul><ul><li>Alcohol or other drug testing </li></ul></ul><ul><ul><li>Hematuria (gross versus microscopic) </li></ul></ul>Blood and Urine Tests
    15. 15. Adjuncts <ul><ul><li>Blunt: AP chest and pelvis </li></ul></ul><ul><ul><li>Penetrating: AP chest and abdomen with markers (if hemodynamically normal) </li></ul></ul>X-ray Studies
    16. 16. Adjuncts <ul><ul><li>Abdominal CT </li></ul></ul><ul><ul><li>Urethrogram </li></ul></ul><ul><ul><li>Cystogram </li></ul></ul><ul><ul><li>IVP </li></ul></ul><ul><ul><li>GI studies </li></ul></ul>Contrast Studies Don’t delay definitive care! Caution
    17. 17. Diagnostic Studies Blunt Trauma
    18. 18. Diagnostic Studies Penetrating Trauma – Hemodynamically Normal <ul><ul><li>Lower chest wounds </li></ul></ul><ul><ul><li>Serial exams, thoracoscopy, laparoscopy, or CT scan </li></ul></ul><ul><ul><li>Anterior abdominal stab wounds </li></ul></ul><ul><ul><li>Wound exploration, DPL, or serial exams </li></ul></ul><ul><ul><li>Back and flank stab wounds </li></ul></ul><ul><ul><li>DPL, serial exams, or double- or triple-contrast CT scan </li></ul></ul>
    19. 19. FAST exam
    20. 20. FAST <ul><li>Focused </li></ul><ul><li>Assessment using </li></ul><ul><li>Sonography for </li></ul><ul><li>Trauma </li></ul>
    21. 21. RUQ <ul><li>1) RUQ (perihepatic) view : </li></ul><ul><li>Transducer orientation : In-between pt’s ribs </li></ul><ul><li>Transducer placement : right midaxillary line at level of 9th to 11th intercostal space </li></ul><ul><li>Key Structures : right kidney, liver, diaphragm </li></ul><ul><li>Pathology : fluid in Morison’s pouch, hemothorax </li></ul>                                       
    22. 22. Right upper quadrant <ul><li>R Kidney </li></ul>RUQ Liver R Kidney Diaphragm
    23. 23. Morrison’s pouch + fluid                                        
    24. 24. LUQ <ul><li>LUQ (perisplenic) view : </li></ul><ul><li>Transducer orientation : coronal (indicator towards pt’s head) </li></ul><ul><li>Transducer placement : left posterior axillary line at level of 5th to 8th intercostal space </li></ul><ul><li>Remember “knuckles to the bed” because of posterior location of left kidney </li></ul><ul><li>Key Structures : left kidney, spleen, diaphragm </li></ul><ul><li>Pathology : fluid in splenorenal space or between sleen and diaphragm, hemothorax </li></ul>                                     
    25. 25. Left Upper Quadrant LUQ L Kidney Spleen Diaphragm
    26. 26. LUQ +fluid
    27. 27. Pericardial <ul><li>Subxiphoid view : </li></ul><ul><li>Transducer orientation : indicator towards pt’s right </li></ul><ul><li>Transducer placement : 15 degree angle to the chest wall aiming transducer towards the patient’s left shoulder. Key is to lay probe almost parallel to patient </li></ul><ul><li>Key Structures : liver, diaphragm, pericardial space </li></ul><ul><li>Pathology : pericardial effusion </li></ul>
    28. 28. Subxiphoid view                              
    29. 29. Pericardial Long <ul><li>5) Parasternal Long view : </li></ul><ul><li>Transducer placement : perpendicular to the chest wall at the 3rd or 4th intercostal space immediately left of the sternum with indicator pointing towards pt’s left shoulder </li></ul><ul><li>Key Structures : right ventricle, left ventricle, left atrium, and pericardial space </li></ul><ul><li>Pathology : pericardial effusion </li></ul>
    30. 30. Parasternal Long View Parasternal Long LA RV LV Pericardial space
    31. 31. Pelvic views Longitudinal and Transverse                                      
    32. 32. PELVIS <ul><li>Suprapubic views (Longitudinal and Transverse) : </li></ul><ul><li>Transducer orientation : </li></ul><ul><ul><li>longitudinal (indicator towards pt’s head) </li></ul></ul><ul><ul><li>transverse (indicator towards pt’s right) </li></ul></ul><ul><li>Transducer placement : just above pubic symphysis along midline of abdomen </li></ul><ul><li>Key Structures (males) : bladder, retrovesicular space </li></ul><ul><li>Key Structures (females) : bladder, uterus, pouch of Douglas </li></ul><ul><li>Pathology : fluid in retrovesicular space or pouch of Douglas </li></ul>Suprapubic Female (Longitudinal) Bladder Pouch of Douglas Bladder Suprapubic Male (Transverse) Retrovesicular space
    33. 33. Longitudinal view +
    34. 34. Transverse +
    35. 35. Explosions <ul><ul><li>ABCDE </li></ul></ul><ul><ul><li>Combination mechanism </li></ul></ul><ul><ul><ul><li>Blunt </li></ul></ul></ul><ul><ul><ul><li>Penetrating fragments (multiple) </li></ul></ul></ul><ul><ul><ul><li>Blast </li></ul></ul></ul>Consider proximity, enclosed space, multiple fragments and secondary impacts (thrown or fall from height).
    36. 36. Laparotomy Who requires a laparotomy?
    37. 37. Laparotomy Who requires a laparotomy?
    38. 38. Laparotomy Indications for Laparotomy – Blunt Trauma <ul><ul><li>Hemodynamically abnormal with suspected abdominal injury (DPL / FAST) </li></ul></ul><ul><ul><li>Free air </li></ul></ul><ul><ul><li>Diaphragmatic rupture </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Positive CT </li></ul></ul>
    39. 39. Laparotomy Indications for Laparotomy – Penetrating Trauma <ul><ul><li>Hemodynamically abnormal </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Evisceration </li></ul></ul><ul><ul><li>Positive DPL, FAST, or CT </li></ul></ul>Early operation is usually the best strategy for GSW
    40. 40. Pelvic Fractures <ul><ul><li>Significant force </li></ul></ul><ul><ul><li>Associated injuries </li></ul></ul><ul><ul><li>Pelvic bleeding </li></ul></ul><ul><ul><ul><li>Venous / arterial </li></ul></ul></ul>
    41. 41. Pelvic Fractures <ul><ul><li>Inspection </li></ul></ul><ul><ul><ul><li>Leg-length discrepancy, external rotation </li></ul></ul></ul><ul><ul><ul><li>Open or closed </li></ul></ul></ul><ul><ul><li>Palpation of pelvic ring, stability </li></ul></ul><ul><ul><li>Rectal / GU / vaginal exam </li></ul></ul><ul><ul><ul><li>Open or closed? Palpate prostate </li></ul></ul></ul>Assessment of Pelvic Fractures
    42. 42. Pelvic Fractures How do I manage patients with pelvic fractures?
    43. 43. Pelvic Fractures <ul><ul><li>AB, as usual </li></ul></ul><ul><ul><li>C: Control hemorrhage </li></ul></ul><ul><ul><ul><li>Wrap / Binder </li></ul></ul></ul><ul><ul><ul><li>Rule out abdominal hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Angiography, fixation, open surgery </li></ul></ul></ul>How do I manage patients with pelvic fractures?
    44. 44. Pelvic Fractures Hemodynamically Abnormal Patients Surgical consult Pelvic wrap Intraperitoneal gross blood? Yes No Laparotomy Angiography Control hemorrhage Fixation device
    45. 45. <ul><li>Delayed intervention for abdominal hemorrhage </li></ul><ul><li>Occult intraabdominal / retroperitoneal injuries </li></ul><ul><li>Back and flank wounds </li></ul><ul><li>Repeated manipulation of a fractured pelvis </li></ul><ul><li>Spinal cord injury / altered sensorium </li></ul>Pitfalls Pitfalls
    46. 46. Summary <ul><li>ABCDEs and early surgical consultation </li></ul><ul><li>Evaluation and management vary with mechanism and physiologic response </li></ul><ul><li>Repeated exams and diagnostic studies </li></ul><ul><li>High index of suspicion </li></ul><ul><li>Early recognition / prompt laparotomy </li></ul>
    47. 47. Case Scenario <ul><li>35-year-old male passenger in high-speed motor vehicle collision </li></ul><ul><li>BP: 105/80; Pulse: 110; RR: 18 </li></ul><ul><li>GCS score: 15 </li></ul><ul><li>Complaining of pain in chest, abdomen, and pelvis </li></ul>What injuries do you suspect and how would you manage this patient?
    48. 49. Thanks to… <ul><li>Viam Dinh, MD </li></ul><ul><li>http://www.sonoguide.com/FAST.html </li></ul>