5. Penetrating Abdominal Injury
• Gunshot wounds (GSWs): s a rule GSWs virtually always penetrate the
peritoneum or retro peritoneum, and require ex-lap
• Stabbing: Severity depends on the depth and habitus of the patient
• Most commonly damaged organ is the liver
• Initial management
• Primary Survey: Chief concern is blood loss. Fluid replacement to maintain systolic
pressure > 90mmHg (Fluid Overload can cause Abdominal Compartment syndrome)
• Focused Physical examination
• Trauma Labs, Plain films
• CT assessment in stable patients
• FAST in unstable patients
• Prophylactic antibiotics to cover GI flora (Cefoxitin OR Gentamicin/Clindamycin) in case the
peritoneum or retro peritoneum is violated
6. Penetrating Abdominal Injury
• Operative management
• Exploratory laparotomy: All GSWs. Stab wound can be treated conservatively or
require exploratory laparotomy
• Investigations
• Plain films (CXR, AXR): Ordered on all abdominal trauma patients. C-spine and
Lumbar spine films may be useful as well
• CT: Most common and most accurate imaging modality for penetrating and blunt
abdominal injury. Perform in hemodynamically stable patients.
• Focused abdominal sonography for trauma (FAST) - bleeding in the abdomen as
well as the pericardium. Perform on most patients. Ideal for non-stable patients
because of its relative efficiency.
• Diagnostic peritoneal Lavage (DPL): Widely replaced by FAST (less invasive)
7. Blunt Abdominal Injury
• Causes: Motor Vehicle Accidents, Direct blow, Crushing injuries,
Deceleration injury, Shearing forces
• The organs most commonly damaged are the spleen and liver
• Initial management
• Primary survey: Very likely to get a splenic injury. Palpate LUQ to get a
better idea.
• Focused physical examination: Peritoneal signs warrant ex lap.
• Trauma labs, plain films
• CT in stable patients
• FAST in unstable patients
8. Blunt abdominal injury
• Indications for operative management (Exploratory Laparotomy)
• Blunt abdominal trauma + Hemodynamic instability
• Peritoneal signs
• Evisceration
• Suspected or Confirmed Diaphragmatic injury
• Rectal perforation
• Bleed per stomach
• Free intraperitoneal or retroperitoneal air
• Positive FAST
• Positive DPL
9. Diaphragm
• Sx: Chest pain, Dyspnea, Respiratory distress, Decreased breath
sounds, Signs of Chest trauma, Abdominal pain or tenderness
• CXR: 50% show abdominal viscera in hemithorax; elevated
hemidiaphragm
• Management: Laparotomy or Laparoscopy for repair
• Complications of delayed diagnosis: Hernia, Strangulation,
Increased morbidity and mortality
10. Liver
• ≥ AAST liver injury Grade III require operative management
• Exploratory laparotomy: Penetrating trauma involving the liver
• Observation: Blunt trauma involving the liver if:
• Hemodynamically stable; AND
• No peritoneal symptoms; AND
• No associated injuries requiring laparotomy; AND
• No need for excessive transfusion
• Repeat CT 2-3 days after
11. Spleen
• #1 most injured organ in blunt abdominal injury
• Expect when there is injury to the left lower rib cage (7th, 8th, 9th, 10th
L Rib Fracture)
• 30% will present with hypotensive shock
• Operative management
• Immediate laparotomy to assess the damage
• Hemodynamic instability
• Expanding hematoma
• AAST spleen injury ≥ grade III (hematoma >50% of surface are or laceration > 3 cm)
• Patient has a coagulopathy/ on anticoagulants
• Splenectomy and subsequent vaccination against encapsulated bacteria
12. Spleen
• Non-operative management
• Indications: Stable patients who do not require laparotomy
• Admission + strict bed rest 2-3 days
• NPO
• NG decompression
• Serial hematocrit
• At 3 days: Follow up CT, may resume diet, light activity
• Next 3 months: light activity
13. Stomach
• Bloody aspirate from NG tube
• CXR: Subdiaphragmatic free air
• CT: Free abdominal fluid
• Management
• Antibiotics to cover gut flora
• Repair
14. Bowel
• CXR: subdiaphragmatic free air
• CT: hollow viscus injury
• Management
• Antibiotics to cover gut flora
• Exploratory laparotomy
16. Pancreas
• Uncommon and difficult to diagnose
• May present weeks or months later (with a history of trauma) as
pancreatic pseudocysts ( seen on ultrasound or CT)
20. Genitourinary Trauma
• Clues to GU trauma
• Lumbar or lower rib fracture (think renal)
• Pelvic fracture (think bladder, urethra)
• Abnormal prostate exam on DRE (think urethra)
• Blood at urethral meatus (think urethra)
• Perineal or scrotal hematoma (think urethra)
• Gross hematuria (think bladder)
• Flank pain or hematoma
• Shock (think significant renal bleeding if in GU)
21. Kidneys
• Most common urologic injury.
• Susceptible to blunt trauma (Suspended in the Retroperitoneum by hila
and perineal fat)
• Fracture of lower ribs can lacerate the kidneys
• Severe injury to the renal vasculature can lead to shock
• Pts w/ pre-existing renal anomalies (Polycystic, tumors,
hydronephrosis etc.) are at increased risk and may suffer from
apparently benign trauma
• Suspicion is based on a combination of symptoms and imaging
• Managed conservatively
23. Kidneys - Renal Injury
Grades
Grade I:
Contusion
Subcapsular hematoma
Grade II
Perirenal hematoma
Cortical laceration < 1 cm
Grade III
Cortical laceration > 1 cm
Grade IV
Cortical laceration that penetrates the CMJ
Thrombosis of a renal segmental artery
Grade V
Thrombosis of the main renal artery
Multiple major lacerations (”Shattered Kidney”)
Disruption of the renal hilum
24. Ureters
• Least commonly injured part of the GU.
• Usually caused by penetrating trauma
• Urethral trauma in peds is possible with decelerating injury
• Proximal 1/3 most likely to be damaged
• Difficult do dx and may present later with infection and flank mass
• Sx: Colicky abdominal pain, flank mass (urinoma), hematuria
(possible but not necessary)
• Investigation: Helical CT w/IV contrast
• Management: Complex. Consult urology
26. Bladder
• Sx: Gross hematuria on Foley catheterization, Lower abdominal pain,
Inability or difficulty in voiding
• Investigations: Retrograde Cystogram by CT
• Extraperitoneal rupture (85%)
• Rupture at the trigone of the bladder
• Cystogram shows contrast surrounding the bladder
• Consult urology, can heal non-surgically
• Intraperitoneal rupture (15%)
• Rupture at the dome of the bladder
• Cystogram shows contrast extending into the abdomen and surrounding bowel walls
• Consult urology, will require surgery
29. Urethra
• Almost exclusively a male injury.
• Blood at urethral meatus is a urethral injury until proven otherwise (by
RUG)
• Usually blunt trauma, pelvic fracture
• Absolute Contraindication for Foley catheter
• Sx: Urinary urgency, inability to void, blood at the urethral meatus,
Non-palpable/boggy/high-riding prostate on DRE, Resistance when
placing Foley catheter
30. Urethra
• Investigation: Retrograde Urethrogram. Normal RUG allows placement of
Foley. Abnormal RUG = suprapubic catheter
• Posterior urethral injury
• Injury to the prostatic or membranous urethra; or just “the urethra” in women
• Associated w/pelvic fracture
• Dx: RUG: Extravasation of contrast superior to the urogenital diaphragm
• Tx: Suprapubic catheter, CT cystogram (35% are associated with bladder injury),
Urology consult
• Anterior urethral injury
• Injury to the penile urehtra
• Assocaited with straddle injury, penetrating trauma, and iatrogenic (instrumentation)
• Sx :Often leads to hematoma along the penile shaft that may extend into the
abdominal wall and scrotum (”Butterfly hematoma”)
• Dx: RUG, extravasation of contrast inferior to the urogenital diaphragm
32. Paediatric Trauma
• Size, Shape and Surface Area
• Smaller body mass, less fat, and less connective tissue
• Closer proximity of multiple: susceptible to multisystem injury
• Head is proportionately larger than adults: Susceptible to traumatic brain
injuries
• High body surface are to body mass ratio: susceptible to hypothermia, and
can complicate the treatment of hypotension
• Skeleton
• Fractures are less likely, even when there is underlying damage to internal
organ damage. Presence of Fractures suggest transfer of massive amounts of
energy and underlying organ injury (pulmonary contusion and TBI should be
suspected)
33. Paediatric Trauma
• Airway
• Large occiput causes passive flexion of the C-spine when lying supine: Use a 1-inch Padding to
preserve neutral alignment of the spinal cord
• Soft tissue of the infant’s oropharynx are relatively large compared to tissue in the oral
cavity: compromises visualization of the larynx during intubation
• Funnel shaped larynx encourages secretions to accumulate in the retropharynx
• Larynx and vocal cords are positioned more cephalad and anterior in the neck. This makes it
difficult to visualize when the child’s head is in the normal, supine, anatomical position during
intubation
• Short trachea: Can result in intubation of the right main-stem bronchus, inadequate ventilation,
accidental tube dislodgment and/or mechanical barotrauma
• Breathing
• Fragile and immature tracheobranchial tree and alveoli: risk of iatrogenic barotrauma during
assisted ventilation
• Thinner chest wall: requires care when using 14-18 G catheters in infants and small children as
they may cause tension pneumothorax. Also need smaller chest tubes
34. Paediatric Trauma
• Circulation
• Increased physiologic reserve: able to maintain systolic BP in the normal range even
in the presence of shock
• High BSA to Body Mass ratio, increased metabolic rate, thin skin, and low
subcutaneous tissue: Increased susceptibility to hypothermia
• Sx of hypovolemia: Tachycardia, decreased skin perfusion, weak peripheral pulses,
narrow pulse pressure (<20mmHg), skin mottling (in infants and young children),
decreased level of consciousness, dulled response to pain,
• Hypotension = decompensated shock and >45% loss of circulating blood volume
• Damage control resuscitation: restrict crystalloids, early administration of balanced
ratios of pRBCs, FFP and platelets - interrupts the lethal triad
35. Paediatric Trauma
• Chest trauma
• Pliable chest wall: Pulmonary contusion is common. Rib fractures and
mediastinal injuries are uncommon
• Mobile mediastinal structures: more susceptible to tension pneumothorax
(most common immediately life-threatening injury in children).
• Abdominal trauma
• CT radiation must be kept As Low As Reasonably Achievable (ALARA):
CT only when medically reasonably, when the result will change management,
only the areas of interest and use the lowest dose possible
• Most have self-limited intra-abdominal injuries
• Mesenteric and small bowel avulsion injuries are more common
• Bladder rapture is more common because of the shallow pelvis
36. Paediatric Trauma
• Head Trauma
• Smaller SAS: less protection to the brain, more likely to sustain parenchymal damage
• Decreased cerebral blood flow: susceptible to cerebral hypoxia and hypercarbia
• Open cranial sutures and fontanelles: hypotension as a result of significant blood
loss into the subgaleal, intraventricular, or epidural
• Mobile sutures and fontanelles: more tolerant to expanding intracranial mass
lesions or brain trauma. Sx may be hidden until rapid decompensation occurs. Suspect
severe injury in infants who are not in coma BUT have bulging fontanelles or suture
diastases
• Impact seizures, or seizures that occur after brain injury are more common in children
and are usually self-limited
37. Geriatric Trauma
• Decreased physiologic reserve - decreased adaptive and homeostatic
response. Leads to increased susceptibility to injuries that are commonly
tolerated by younger patients.
• Commonly have pre-existing conditions that impact morbidity and mortality. 2
times more likely to die than those without PECs.
• Falls
• Risk increases with age. Most common mechanism of fatal injury in the elderly
• Non-fatal falls are common in women
• Fractures associated with falls are common in women
• Common cause of TBI in the elderly
• Risk: Advanced age, Physical impairment, History of previous fall, Medications,
Dementia, Unsteady gait,Visual, cognitive and neurologic impairments, and
Environmental factors (loose rugs, poor lighting, slippery or uneven surfaces)
38. Geriatric Trauma
• Motor Vehicle Accidents
• Risk: Slow reaction time, Larger blind spot, Decreased cervical mobility,
Decreased hearing, Cognitive impairment
• Stroke, AMI, Dysrhythmias can precipitate crashes
• Burns
• Risk: Decreased reaction time, Impaired hearing and vision, Inability to escape
burning structures
• Paucity of hair follicles: commonly have full-thickness burns from
burn injuries that commonly re-epithelialize in young patients.
39. Geriatric Trauma
• Airway
• Decreased protective reflexes, Macroglossia, Loose dentures: Requires timely
establishment of a definitive airways
• Edentulous: easier intubation, bag-mask ventilation more difficult
• Arthritic changes: Jaw-thrust, Chin-lift, and C-spine stabilization difficult
• Increased risk of cardiovascular depression in rapid sequence intubation: reduce
dose of sedatives in RSI to about 20-40%
• Breathing
• Reduced lung compliance, Increased kyphoscoliosis: higher risk of respiratory
failure due to increased work of breathing
• Suppressed heart rate response to hypoxia: respiratory failure presents insidiously
• Loss of bone density: increased risk of rib fractures, commonly complicated with
pneumonia
40. Geriatric Trauma
• Circulation
• Pre-existing cardiac disease or hypertension: recognize that stroke, MI or
dysrhythmia may have triggered the incident leading to the injury
• Lack of a classical response to hypovolemia: fixed heart rate and cardiac
output. Response to hypovolemia is by increasing systemic vascular resistance
(Thus hypotension is defined as systolic BP ≤ 110mmHg)
• B-blockers: blocks the expected physiological response to hypovolemia
• Anticoagulants, Antiplatelet, Direct thrombin inhibitors: increased risk of
bleeding. Requires rapid reversal if available.
41. Geriatric Trauma
• Disability
• Cerebral atrophy: permits intracranial pathology to present with a normal
neurological exam
• Degenerative spine disease: increased risk of fractures and spinal cord injury
with low-kinetic ground-level falls
• Prescribed anticoagulant and antiplatelet medication: high risk of
intracerebral hemorrhage. Aggressive reversal with prothrombin complex
concentrate, plasma and vitamin K
• Atherosclerotic disease: contributes to primary or secondary brain injury
• Pre-existing neurological or psychiatric disease
42. Geriatric Trauma
• Exposure and Environment
• Loss of subcutaneous fat, nutritional deficiency, chronic medical
conditions - increased risk of hypothermia and complications of immobility
(pressure sores and delirium)
• Early evaluation and liberation from spine boards and cervical collars as soon
as possible
• Pad bony prominences when needed
• Prevent hypothermia
44. Trauma in Pregnancy
• Blunt Trauma
• Sx: external contusions and abrasions of the abdomen
• Indirect injury to the fetus: rapid compression, deceleration, contrecoup effect
• Shear forces: cause abruptio placentae
• Unrestrained MVA: high risk of premature delivery and fetal death
• Lap belt restrained in MVA: uterine rupture, abruptio placentae
• Shoulder restraints + lap belt in MVA: reduces direct and indirect fetal injury
• Penetrating Trauma
• Penetrating trauma to the upper abdomen: complex intestinal injury (peritoneal signs are
less evident due to expansion and attenuation of the abdominal wall musculature)
• Penetrating trauma to the gravid uterus: good maternal outcome, poor fetal outcome
46. Trauma in Pregnancy
• Blood Volume and Composition
• Increased plasma volume: healthy pregnant patient can loose 1200-1500mL of
blood before exhibiting signs and symptoms of hypovolemia (however the fetus may
be in distress)
• Fibrinogen level doubles in late pregnancy: A normal fibrinogen can indicated early
DIC
• Cardiac Output
• Cardiac Output increases by 1.0 - 1.5L/min by the 10th week of pregnancy
• IVC compression in Supine position decreases CO by 30%: manually displace the
uterus to the left or log roll to the left 15-30 degrees to relieve pressure on the IVC
• Heart rate increased by 10-15 bpm: consider when interpreting tachycardia as a
response to hypovolemia
47. Trauma in Pregnancy
• Respiratory System
• Increased tidal volume → Increased minute ventilation → Hypocapnia
(PaCO2 30mmHg) common in late pregnancy: thus PaCO2 35-40mmHg may
indicated respiratory failure
• Decreased residual volume associated with diaphragmatic elevation, Increased
lung markings and prominent pulmonary vessels in XCR
• Increased oxygen consumption and increased fetal sensitivity to maternal
hypoxia: important to ensure adequate arterial oxygenation when resuscitating.
Maintain SpO2 of 95%
• Elevated diaphragm: may requires higher placement of chest tube
48. Trauma inPregnancy
• Gastrointestinal system
• Delayed gastric emptying: requires early decompression to prevent aspiration.
• Urinary System
• Increased GFR and RBF
• Serum Creatinine and BUN fall to half of normal pre-pregnancy levels
• Glycosuria is common in pregnancy
• Musculoskeletal system
• Symphysis pubis widens 4-8mm and sacroiliac space increases by the 7th month
of gestation - consider when interpreting pelvic films
• Neurological system
• Eclampsia can mimic head injury: seizures in eclampsia are associated with
hypertension, hyperreflexia, proteinuria, and peripheral edema
