Trauma

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4. Present with deceptively
unimpressive physical exams
Details of mechanism of injury
should be elicited in order to
appropriately manage said
patients
Gunshot penetrating trauma
has a much higher morbidity
and mortality compared to
stab wound
Bedside sonography is
increasingly useful for
diagnosis of hemiperitoneum
in blunt abdominal trauma
FAST is effectively taking over
DPL currently

5. Anterior Abdomen
• area between the costal margins superiorly, the
inguinal ligaments and symphysis pubis inferiorly,
and the anterior axillary lines laterally
• Most of the hollow viscera are at risk when there
is an injury to the anterior abdomen
Thoracoabdomen
• area inferior to the nipple line anteriorly and the
infrascapular line posteriorly, and superior to the
costal margins
• encompasses the diaphragm, liver, spleen, and
stomach
• fractures of the lower ribs and penetrating
below the nipple line can injure the abdominal
viscera

6. Flank
• area between the anterior and posterior
axillary lines from the sixth intercostal space
to the iliac crest
Back
• area located posterior to the posterior
axillary lines from the tip of the scapulae to
the iliac crests
• This includes the posterior thoracoabdomen
• Musculature in the flank, back, and
paraspinal region acts as a partial protection
from visceral injury

7. The flank and back contain the retroperitoneal space
Injuries to the retroperitoneal visceral structures are
difficult to recognize because they occur deep within the
abdomen and may not initially present with signs or
symptoms of peritonitis
In addition, the retroperitoneal space is not sampled by
diagnostic peritoneal lavage (DPL) and is poorly visualized
with focused assessment with sonography for trauma
Pelvic cavity is surrounded by the pelvic bones, containing the
lower part of the retroperitoneal and intraperitoneal spaces
It contains the rectum, bladder, iliac vessels, and female
internal reproductive organs

8. Retroperitoneal Structures
Suprarenal glands
Aorta and IVC
Duodenum (2nd through 4th
parts)
Pancreas (except tail)
Ureters
Colon (ascending and
descending)
Kidneys
Esophagus (lower 2/3rd )
Recturm

9. pubic symphysis diastasis and significant
asymmetric widening of the left SI joint. These
findings are suggestive of an open hemipelvis,
which is seen in AP compression type 2 injuries.
Bilateral pubic rami fractures are also seen
AP pelvic radiography in a trauma patient with
lateral compression injury type 2. Note the
characteristic right sacral impaction or buckle
fracture with minimally widening of the SI joint and
the overlapping pubic rami fractures right-sided.
The sacral fractures might be subtle on radiograph
Fracture of the right superior and inferior
pubic rami and the right sacral ala. The pubic
symphysis and sacroiliac joints remain
normally aligned

11. • CASE SCENARIO
• 32-YEAR-OLD MALE, HELMETED MOTORCYCLIST, HIGH-
SPEED COLLISION, HEAD-ON INTO THE SIDE OF A
VEHICLE THAT PULLED OUT IN FRONT OF HIM
• PATIENT REPORTS COMPLAINS OF PAIN IN CHEST,
ABDOMEN, AND PELVIS
• BP 90/75; HR 122; RR 22, AND GCS 15
• BACKBOARD AND C-COLLAR PLACED BY PARAMEDICS

12. • CASE SCENARIO
• 32-YEAR-OLD MALE, HELMETED
MOTORCYCLIST, HIGH-SPEED COLLISION, HEAD-
ON INTO THE SIDE OF A VEHICLE THAT PULLED
OUT IN FRONT OF HIM
• PATIENT REPORTS COMPLAINS OF PAIN IN
CHEST, ABDOMEN, AND PELVIS
• BP 90/75; HR 122; RR 22, AND GCS 15
• BACKBOARD AND C-COLLAR

14. Case Scenario Progression
• EMS reports:
• Patient found 10 feet (3 meters) from his
motorcycle
• Patient lying on R side, wearing a helmet
• Had been travelling at 75kmph
• Patient reports:
• Hard R sided landing
• No allergies, no previous medical history
or current medications
Discussion Question:
1. Based on the reported mechanism of injury,
what intra-abdominal and/or pelvic injury is
the patient likely to have sustained?
2. How would the risk of intra-abdominal injury
change if the patient described striking the
handlebar into the epigastrium?
3. How would the risk of intra-abdominal injury
change if a penetrating injury was observed?

15. Penetrating Trauma
•Stab wounds and low-energy gunshot wounds cause tissue damage by
lacerating and tearing. High-energy gunshot wounds transfer more kinetic
energy, causing increased damage surrounding the track of the missile due
to temporary cavitation.
•Stab wounds traverse adjacent abdominal structures and most commonly
involve the liver (40%), small bowel (30%), diaphragm (20%), and colon
(15%)
•Gunshot wounds most commonly injure the small bowel (50%), colon
(40%), liver (30%), and abdominal vascular structures (25%).
•The type of weapon, the muzzle velocity, and type of ammunition are
important determinants of degree of tissue injury
•In the case of shotguns, the distance between the shotgun and the patient
determines the severity of injuries incurred

16. Blunt Trauma
• A direct blow, such as contact with the lower rim of a steering wheel, bicycle or motorcycle handlebars, or
an intruded door in a motor vehicle crash, can cause compression and crushing injuries to
abdominopelvic viscera and pelvic bones
• Shearing injuries are a form of crush injury that can result when a restraint device is worn inappropriately
• Deceleration injuries are also seen in which there is differential movement of fixed and mobile parts of the
body
• The organs most frequently injured are the spleen (40% to 55%), liver (35% to 45%), and small bowel (5%
to 10%)
Blast Trauma
• Blast injury from explosive devices occurs through several mechanisms, including penetrating fragment
wounds and blunt injuries from the patient being thrown or struck by projectiles
• Must consider the possibility of combined penetrating and blunt mechanisms in these patients
• Patients close to the source of the explosion can incur additional injuries to the tympanic membranes,
lungs, and bowel related to blast overpressure

17. abdomi
nal
trauma
Solid organ
injuries
hollow
visceral
injuries
retroperitoneal
injuries
diaphragmatic
injuries

19. Case Scenario Progression
On examination:
• Right-sided lower chest tenderness
• Multiple abrasions and contusions
on right chest, abdomen, and flank
• Tender Right upper quadrant, Right
flank, and suprapubic region
• Pain on palpation of the anterior
pelvis
• No blood at the urethral meatus
• Rectal examination is normal.
• Vital signs following 1 litre of
warmed crystalloid solution:
• BP 108/72; HR 110; RR 20; GCS 15

20. 1.In hypotensive patients, the goal is to rapidly identify an abdominal
or pelvic injury and determine whether it is the cause of hypotension
2.Hemodynamically normal patients without signs of peritonitis may
undergo a more detailed evaluation to determine the presence of
injuries that can cause delayed morbidity and mortality
The abdominal examination is conducted in a systematic sequence:
inspection, auscultation, percussion, and palpation. This is followed by
examination of the pelvis and buttocks, as well as; urethral, perineal,
and, if indicated, rectal and vaginal exams
When rebound tenderness is present, do not seek additional evidence
of irritation, as it may cause the patient further unnecessary pain
Unexplained hypotension may be the only initial indication of major
pelvic disruption
Mechanical instability of the pelvic ring should be assumed in patients
who have pelvic fractures with hypotension and no other source of
blood loss
Physical exam findings suggestive of pelvic fracture include evidence of
ruptured urethra (scrotal hematoma or blood at the urethral meatus),
discrepancy in limb length, and rotational deformity of a leg without
obvious fracture
oAvoid multiple examinations and distraction of the pelvis
oRepeated manipulation of a fractured pelvis can aggravate
hemorrhage
oApply a pelvic binder correctly and early to limit hemorrhage
oThe absence of hematuria does not exclude an injury to the
genitourinary tract. A retrograde urethrogram is mandatory when the
patient is unable to void, requires a pelvic binder, or has blood at the
meatus, scrotal hematoma, or perineal ecchymosis
oTo reduce the risk of increasing the complexity of a urethral injury,
confirm an intact urethra before inserting a urinary catheter
Assessment and physical
examination

21. Pancreatic
injuries
• Subtle signs and symptoms
making diagnosis elusive
• Rapid deceleration injury or
a severe crush injury
• Unrestrained drivers who hit
the steering column
Duodenal
Injury
• Clinical signs are often slow
to develop
• With high speed vertical or
horizontal decelerating
trauma
Diaphragmatic
injuries
• when bowel sounds can be
auscultated in the thoracic cavity
• herniation of abdominal contents
into the thoracic cavity
• Abd xray shows ng tube in thorax
and blurring of diaphragm

22. Grey-Turner Sign
• Bluish discoloration of lower flanks, lower back
• Associated with retroperitoneal bleeding of pancreas,kidney or pelvic
fracture
• Seen in blunt abdominal trauma
Cullen Sign
• Bluish discoloration around umbilicus
• Seen in blunt abdominal trauma
• Indicates peritoneal bleeding
Kehr sign
• Shoulder pain while supine, caused by diaphragmatic irritation
• Seen in ruptured spleen (splenic injury)

23. Ballance sign
• Dull percussion in LUQ
• Sign of splenic injury
• Blood accumulating in subcapsular or extracapsular spleen
Labial and scrotal sign
• Pooling of blood in scrotal and labia
London sign / seat belt sign
• Patterned Bruising of Blunt Abdominal Trauma
• It indicates that the impacting force is sharp and severe enough to
cause visceral injury

24. Cbc
Blood grouping &
crossmatching
Coagulation profile
CXR
?free intraperitoneal gas
Herniation of abdominal
contents through ruptured
diaphragm or other
abnormalities
POCUS(FAST/EFAST)
Can be performed in the resus room
Aim to assessment is to detect
haemoperitoneum
91%-100% sensitive
98% specific in detecting hemiperitonium
Less sensitive in detecting nature of injury
particularly in liver/pancreas/bowel
As a result patients with a normal FAST
requires further evaluation
CT (contrast enhanced)
Can detect very small quantities of blood in
abdominal cavity
To assess retroperitoneum
Penetrating flank trauma
Mild abdominal tenderness in alert patients
Highly sensitive in detecting solid organ injury
Helical abdominal CT has higher sensitivity for
detecting blunt bowel injury
Contraindicated in hemodynamically unstable
patients
Urethrography
Cystography
Intravenous pyelogram
Gastrointestinal contrast
studies

34. INDICATIONS OF
EMERGENCY
LAPAROTOMY

35. •Lateral compression injury, which involves force
directed laterally into the pelvis, is the most
common mechanism of pelvic fracture
•In contrast to AP compression, the hemipelvis
rotates internally during lateral compression,
reducing pelvic volume and reducing tension on
the pelvic vascular structures
•potentially causing injury to the bladder and/or
urethra
•require early hemorrhage control techniques such
as angioembolization
Lateral compression (closed) – 60-70%
•1. Often associated with a motorcycle or a head-on
motor vehicle crash
•2. This mechanism produces external rotation of
the hemipelvis with separation of the symphysis
pubis
•3. Hemorrhage can be severe and life threatening
Anterior-posterior compression (open book) - 15-
20%
1.1.Vertical displacement of the sacroiliac joint can
also disrupt the iliac vasculature and cause severe
hemorrhage
2.2.This vertical shearing disrupts the sacrospinous
and sacrotuberous ligaments and leads to major
pelvic instability
3.3.A fall from a height greater than 12 feet
commonly results in a vertical shear injury
Vertical shear – 5-15%
Hemorrhage is the major potentially reversible factor contributing to mortality
In patients with open pelvic fractures, mortality is approximately 50%

36. Initial management of hypovolemic shock associated
with a major pelvic disruption requires rapid
hemorrhage control and fluid resuscitation
Achieve hemorrhage control early by applying a pelvic
binder, angioembolization, and/ or operative measures
A sheet, pelvic binder, or other device can produce sufficient
temporary fixation for the unstable pelvis when applied at the level
of the greater trochanters of the femur
Carefully monitor patients with pelvic binders for skin ulceration
Recognize that in frail patients, low-energy mechanism pelvic
fractures can cause bleeding requiring treatment and transfusion
•Angiographic embolization is frequently employed to stop arterial
hemorrhage related to pelvic fractures
•Pre- peritoneal packing is an alternative method to control pelvic
hemorrhage when angioembolization is delayed or unavailable
•An experienced trauma surgeon should construct the therapeutic
plan for a patient with pelvic hemorrhage based on available
resource
•Significant resources are required to care for patients with severe
pelvic fractures. Early consideration of transfer to a trauma center is
essential

38. Angiography
The presence of
contrast extravasation
originated from
branches of the left
obturator artery was
confirmed, and later
embolized
supraselectively

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40. Mechanism of injury is
critical when considering
abdominal and/or pelvic
injury
Thorough examinations of
the chest, abdomen, and
pelvis (anterior, lateral,
posterior, and perineum) are
required to avoid missing
significant injuries
Appropriate diagnostic
procedures should be
employed
Surgical intervention is
assessed via clinical findings
and the patient’s response to
management
Early identification and
emergent management of
pelvic hemorrhage can be
lifesaving