Abdominal Trauma Nestor 2007

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Abdominal Trauma Nestor 2007

  1. 1. Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007
  2. 2. The Plan <ul><li>Abdominal Anatomy </li></ul><ul><li>Mechanisms of Injury </li></ul><ul><li>Common Pathology </li></ul><ul><li>Evaluation </li></ul><ul><li>Management </li></ul>
  3. 3. Part 1: Abdominal Anatomy
  4. 4. Abdominal Anatomy Basics <ul><li>ABC’s </li></ul><ul><li>Many organs receiving substantial blood flow </li></ul><ul><li>Potential spaces that can hide hemorrhage </li></ul><ul><li>Hollow organ damage > Peritonitis </li></ul>
  5. 5. Abdominal Anatomy Basics <ul><li>ABC’s </li></ul><ul><li>Many organs receiving substantial blood flow </li></ul><ul><li>Potential spaces that can hide hemorrhage </li></ul><ul><li>Hollow organ damage > Peritonitis </li></ul>
  6. 6. Abdominal Anatomy Basics <ul><li>ABC’s </li></ul><ul><li>Many organs receiving substantial blood flow </li></ul><ul><li>Potential spaces that can hide hemorrhage </li></ul><ul><li>Hollow organ damage > Peritonitis </li></ul>
  7. 7. Abdominal Anatomy Basics <ul><li>ABC’s </li></ul><ul><li>Many organs receiving substantial blood flow </li></ul><ul><li>Potential spaces that can hide hemorrhage </li></ul><ul><li>Hollow organ damage > Peritonitis </li></ul>
  8. 8. Abdominal Anatomy: Four Quadrants
  9. 9. Abdominal Anatomy: Four Quadrants
  10. 10. Abdominal Anatomy
  11. 11. Abdominal Anatomy
  12. 12. Abdominal Anatomy
  13. 13. Abdominal Anatomy
  14. 14. Abdominal Anatomy: Four Quadrants
  15. 15. Alternative Divisions
  16. 16. Intraperitoneal Structures
  17. 17. Retroperitoneal Structures
  18. 18. Upper Abdomen CT
  19. 19. Lower Abdomen CT
  20. 20. Retroperitoneal
  21. 21. Part 2: Mechanisms and Pathology
  22. 22. Abdominal Injuries <ul><li>Blunt vs. Penetrating </li></ul><ul><li>Often both occur simultaneously </li></ul><ul><li>Blunt is the most common mechanism in US </li></ul>
  23. 23. Blunt Abdominal Trauma <ul><li>Direct impact or movement of organs </li></ul><ul><li>Compressive, stretching or shearing forces </li></ul><ul><li>Solid Organs > Blood Loss </li></ul><ul><li>Hollow Organs > Blood Loss and Peritoneal Contamination </li></ul><ul><li>Retroperitoneal > Often asymptomatic initially </li></ul>
  24. 24. Blunt Abdominal Trauma <ul><li>Direct impact or movement of organs </li></ul><ul><li>Compressive, stretching or shearing forces </li></ul><ul><li>Solid Organs > Blood Loss </li></ul><ul><li>Hollow Organs > Blood Loss and Peritoneal Contamination </li></ul><ul><li>Retroperitoneal > Often asymptomatic initially </li></ul>
  25. 25. Blunt Abdominal Trauma <ul><li>Direct impact or movement of organs </li></ul><ul><li>Compressive, stretching or shearing forces </li></ul><ul><li>Solid Organs > Blood Loss </li></ul><ul><li>Hollow Organs > Blood Loss and Peritoneal Contamination </li></ul><ul><li>Retroperitoneal > Often asymptomatic initially </li></ul>
  26. 26. Blunt Abdominal Trauma <ul><li>Direct impact or movement of organs </li></ul><ul><li>Compressive, stretching or shearing forces </li></ul><ul><li>Solid Organs > Blood Loss </li></ul><ul><li>Hollow Organs > Blood Loss and Peritoneal Contamination </li></ul><ul><li>Retroperitoneal > Often asymptomatic initially </li></ul>
  27. 27. Blunt Abdominal Trauma <ul><li>Direct impact or movement of organs </li></ul><ul><li>Compressive, stretching or shearing forces </li></ul><ul><li>Solid Organs > Blood Loss </li></ul><ul><li>Hollow Organs > Blood Loss and Peritoneal Contamination </li></ul><ul><li>Retroperitoneal > Often asymptomatic initially </li></ul>
  28. 28. Liver Lacerations <ul><li>I. Subcapsular Hematoma <10% Surface Area </li></ul><ul><li>II. Subcapsular Hematoma 10-50% </li></ul><ul><li>III. Subcapsular Hematoma >50% </li></ul><ul><li>IV. Parenchymal Disruption of 25-75% </li></ul><ul><li>V. Parenchymal Disruption of >75% </li></ul><ul><li>VI. Liver Avulsion </li></ul>
  29. 30. Splenic Lacerations <ul><li>I. Subcapsular Hematoma <10% Surface Area </li></ul><ul><li>II. Subcapsular Hematoma 10-50% </li></ul><ul><li>III. Subcapsular Hematoma >50% </li></ul><ul><li>IV. Laceration producing devascularization of >25% of the spleen </li></ul><ul><li>V. Shattered Spleen </li></ul>
  30. 32. Evaluation: Be Suspicious <ul><li>Mechanism </li></ul><ul><li>Vitals </li></ul><ul><li>Symptoms </li></ul><ul><li>Associated Injuries </li></ul><ul><li>Elderly or co-morbidities </li></ul><ul><li>Distracting injuries </li></ul><ul><li>Decreased MS/intoxication </li></ul>
  31. 33. Techniques for Evaluation <ul><li>Physical Exam </li></ul><ul><li>Serial exams in awake, alert and reliable pt </li></ul><ul><li>Plain Films </li></ul><ul><li>Abd films little or no use, pelvic are the standard </li></ul><ul><li>Screening </li></ul><ul><li>Diagnostic Peritoneal Lavage (DPL) </li></ul><ul><li>Ultrasound: FAST (serial exams) </li></ul>
  32. 34. Techniques for Evaluation <ul><li>Physical Exam </li></ul><ul><li>Serial exams in awake, alert and reliable pt </li></ul><ul><li>Plain Films </li></ul><ul><li>Abd films little or no use, pelvis are the standard </li></ul><ul><li>Screening </li></ul><ul><li>Diagnostic Peritoneal Lavage (DPL) </li></ul><ul><li>Ultrasound: FAST (serial exams) </li></ul>
  33. 35. Techniques for Evaluation <ul><li>Physical Exam </li></ul><ul><li>Serial exams in awake, alert and reliable pt </li></ul><ul><li>Plain Films </li></ul><ul><li>Abd films little or no use, pelvis are the standard </li></ul><ul><li>Screening </li></ul><ul><li>Diagnostic Peritoneal Lavage (DPL) </li></ul><ul><li>Ultrasound: FAST (serial exams) </li></ul>
  34. 36. FAST: RUQ
  35. 37. FAST: RUQ
  36. 38. FAST: RUQ
  37. 39. Techniques for Evaluation <ul><li>Organ Specific Dx </li></ul><ul><li>Only CT </li></ul><ul><li>Also evaluates retroperitoneum </li></ul><ul><li>Expensive </li></ul><ul><li>Radiation </li></ul><ul><li>Ex Lap </li></ul><ul><li>Laparotomy gold standard for evaluation </li></ul><ul><li>Concomitant treatment </li></ul><ul><li>Retroperitoneum difficult to explore/assess </li></ul>
  38. 40. Techniques for Evaluation <ul><li>Organ Specific Dx </li></ul><ul><li>Only CT </li></ul><ul><li>Also evaluates retroperitoneum </li></ul><ul><li>Expensive </li></ul><ul><li>Radiation </li></ul><ul><li>Ex Lap </li></ul><ul><li>Laparotomy is the gold standard for evaluation </li></ul><ul><li>Concomitant treatment </li></ul><ul><li>Retroperitoneum difficult to explore/assess </li></ul>
  39. 41. Penetrating Trauma Evaluation <ul><li>Mandatory exploration abandoned </li></ul><ul><li>No digital exploration or contrast studies </li></ul><ul><li>Inspect wound to determine if there is violation of the fascia </li></ul><ul><li>Difficult to assess stab wound trajectory </li></ul><ul><li>Determine if gunshot traversed the peritoneal cavity </li></ul>
  40. 42. Management <ul><li>ABC’s </li></ul><ul><li>Fluid resuscitate </li></ul><ul><li>To lap or not to lap? </li></ul><ul><li>Unstable (with no other reason) </li></ul><ul><li>Free air/peritonitis (antibiotics) </li></ul><ul><li>Unexplained free fluid </li></ul><ul><li>Many splenic/liver lacs managed non-operatively or by VIR </li></ul>
  41. 43. Penetrating Flank and Buttock Injuries <ul><li>Potential for peritoneal and/or retroperitoneal injury </li></ul><ul><li>Similar evaluation and management to abdominal </li></ul><ul><li>Buttock injuries may also reach peritoneal and/or retroperitonal structures </li></ul>
  42. 44. Genitourinary Trauma
  43. 45. GU Trauma <ul><li>2-5% of adult traumas </li></ul><ul><li>Vast majority blunt mechanisms </li></ul><ul><li>80% renal injuries </li></ul><ul><li>10% bladder injuries </li></ul><ul><li>Abnormalities (tumor, hydro) increase susceptibility </li></ul><ul><li>Rarely require immediate intervention </li></ul>
  44. 46. Evaluation <ul><li>Rectal - high riding prostate </li></ul><ul><li>Perineum - ecchymosis, lacs </li></ul><ul><li>Genitals - meatal/vaginal blood </li></ul><ul><li>Difficult catheter placement (may need suprapubic) </li></ul><ul><li>UA – hematuria (poor correlation to degree of injury) </li></ul>
  45. 47. Evaluation <ul><li>U/S and Plain films of little use </li></ul><ul><li>CT is the superior imaging modality </li></ul><ul><li>Careful with contrast (nephropathy) </li></ul><ul><li>Angiography remains the gold standard </li></ul><ul><li>IVP/Cystoscopy less useful in the ED </li></ul>
  46. 48. GU Injuries: The Kidneys <ul><li>Kidneys are well protected </li></ul><ul><li>Most commonly bruised </li></ul><ul><li>Pts with a shattered kidney become rapidly unstable </li></ul><ul><li>Renal vascular injuries may result in thrombosed vessels </li></ul>
  47. 49. GU Injuries: The Kidneys <ul><li>Operative management for: </li></ul><ul><li>uncontrolled hemorrhage </li></ul><ul><li>Penetrating injuries </li></ul><ul><li>Multiple lacs </li></ul><ul><li>Shattered kidney </li></ul><ul><li>Avulsed vessels </li></ul>
  48. 50. GU Injuries: The Bladder <ul><li>Contusion </li></ul><ul><li>Rupture: Intra vs. Extraperitoneal </li></ul><ul><li>Extraperitoneal presents with pain, hematuria and inability to void </li></ul><ul><li>Urethral injuries: Anterior vs. posterior </li></ul><ul><li>No Foley for urethral injuries </li></ul>
  49. 51. Retroperitoneal Structures
  50. 52. In Summary... <ul><li>Basic knowledge of anatomy necessary for initial assessment of abdominal trauma </li></ul><ul><li>Peritoneal vs. Retroperitoneal </li></ul><ul><li>Blunt vs. Penetrating </li></ul><ul><li>Don’t miss GU injuries </li></ul>
  51. 53. Thank You

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