Trauma experience

1. ABDOMEN AL AND PELVIC TRAUMA

2. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

3. OBJECTIEVS
 Anatomy
 Trauma mechanism
 physical Exam
 Ajdacent to physical exam
 About pelvic

4. Who has abdominal and pelvic injuries :
- Blunt trauma in toros from direct blow .
- All penetrating injuries in toros below the
trance nipples line above the perineum .

5. CHALLENGES :
 Unrecognized abdominal and pelvic injureis are
going toward preventable death .
 Evaluation of viscus organ inj ‘ solid organ
bleeding ‘ bleeding of pelvic bony structure is
not simple and more difficult if a patient has
alcohol intoxication ‘ use of illicit drug ‘ brain and
spinal cord inj ‘ or ribs and spine trauma .
 Significant blood loss in abdomen is present but
patient has no sign and symptom of peritonitis

6. GOALS IN ABDOMEN AND PELVIC TRAUMA
ASSESSMENT
 Mechanism of trauma
 Force of trauma
 Location of trauma
 Hemodynamic status of patiant

7. ANATOMY
- Anterior abdomen :
Ant axillary line - lateral border
Ribs margin - supeior border
Ing lig + symphysis pubis - inferior border
- Thoraco abdomen
Below the trance nipple line – anteriorly
Infra scapular line _ posteriorly
Above the costal margin _ superiorly

8. Flunck :
Between post and ant axillary line - lateraly
Sixth costal margin - superior
Cresta iliaca - inferior
Back :
Tip of scapula _ superiorly
Post axillary line _ lateraly
Cresta iliaca _ Inferiorly
Thick musculature structure of these region
is a partial barrier against stab and
penetrating wounds .

9. EVALUATION PROBLEMS IN BACK AND FLANCK
Back and flanck made retroperitonial space
which contains ..abdomenal aorta ‘ IVC ‘
doudenum ‘ pancrease ‘ kidneys ‘ ureters ‘
post aspect of ascending and descending
colon
 Remote from physical examination
 There is no spicific sign and symptom of
retroperitoneal compartment inj
 DPL is negative

10. Pelvic cavity :
Made from pelvic bones …..
Ilium ‘ ischium ‘ pubis and sacrum
Its contains : iliac vessels ‘ rectum and
vagina ‘ prostate gland ‘ urethra ‘ bladder
and female reproductive organs ..

11. CAUSES OF ABDOMENAL AND PELVIC TRAUMA
Type of trauma : Blunt tauma and Penetrating trauma
Penetrating trauma :
GSW
Stab wound
Explosion
Blunt trauma :
Collision with motorcycle
Motor vehicle accident
Height fall
Sports trauma
Blast trauma
Crush trauma

12. Mechanism of blunt trauma :
Increase abdomenal pressure ….ruptur of
intra
abdominal organs
Include acceleration ‘ deceleration ‘ crashing
and direct blow
Mechanism of penetrating trauma :
Laceration of tissue
Cutting of tissue
Traverse of tissue
Temporary cavity {tissue damaged}

13. Mechanism of explosion :
By fregments
Blunt trauma
Blast wave
combinde

14. EVALUATION
After ATLS principle …ABC..
All patients categorized by two groups :
Hemodynamicaly stable
Hemodynamicaly unstable-

15. Physical examination:
Inspection – asscultation - palpation and
percussion
Adjunct to physical examination :
Gastric tube – folly catheter – FAST – DPL –X
–ray - CT scan – MRI

16. INSPECTION
Ant abdomen ‘ post abdomen ‘ lower chest ‘
and perineum should be inspected for
-Abrasion
-contusion
-laceration
-penetrating wound
-impaled foreign bodes
-evisceration of omentum and bowal
-pregnancy state

17. The flunck ‘ perineal area ‘ shoud be inspected
for :
Blood at the urethral meatus
Swelling
Bruising
Laceration {vagina ‘ rectum ‘ buttocks }
Leg depormiteis
Differnce between legs { ‫طول‬ }

18. Be carefull :
The patient will be fully undressed
The patient will be rolled cautiously
The inspection will be rapid {warmmed
blanket}

19. AUSCULTATION
-Difficult in noisy emergency room
-Non specific { extra and intra abdomenal inj
can produce the iliues
-Most useful when the patient is normal initialy
And changes over time

20. PERCUSSION AND PALPATION
Peritoneum irritation sign
Deep and superficial abdomenal tenderness
High and rigid prostate gland {sign of pelvic
fructure}
Pelvis fructure
Integrity of rectum mucosa
Grose bleeding
Douglas pouch tenderness
Rectal spincter tone
Pelvic pain and tenderness

21. ADJUNCTS TO PHYSICAL EXAMINATION
After the diagnosis and treated the air way ‘
breathing and circulation problems ……….
Gastric tube :
Goals -relieve acute gastric dilation before DPL
- decompression of stomach
- remove of gastric contents
- reduced the aspiration
If the patient has sever facial fracture exist
basilar skull fracture ‘ the tube should be
inserted orally

22. Folly catheter :
Goals
Relieve retention of the bladder
Decompression the bladder before DPL
Monitoring the urine {tissue perfusion ‘ renal
function ‘ diagnostic}
- In the case of : unstable pelvic fructure ‘
blood in urethral meatus ‘ scrotal
hematoma ‘ perineal echymosis ‘ high –
rigid prostate gland manadate urethrogram
before tube inserting .
- When urethral disruption is present :
require the SPT

23. OTHER STUDIES
When the patient is hemodynamicaly
abnormal
Rapid evaluation is required this can by
either :
FAST and DPL
Only contraindication ; existing indication for
laparatomy .

24. FAST
- Non invasive
- With out pain
- Can repeat it over time in normal patient
initialy
- No special room { can do it bedside}
- Has more spceficity and sensetivity
comparable DPL
- No contraindication
- We can do it during secends

25. FAST
Pericardial sac
Hepatorenal
Splenorenal
Douglas pauoch

26. DPL
- When we have no FAST and CT scan …use
it
-We can do it rapidly
Negatives :
it is invasive
we have to experince to do it
conclusion :
positive for laparatomy : free aspiration of
blood > 10 ml ‘ vegetable ‘ GI contents or
bile
if gross blood < 10 ml : abdomenal levage
with 1000 ml take a sample for lab exam
….

27. CONTRAINDICATION
- Obesity
- Cirrhosis
- Coagulopathy
- History of laparatomy

28. X – RAY
- In thoraco abdominal wounds to recognized
pneumothorax and hemothorax
- To recognized the pneumoperitoneum
- To recognized retroperitoneal air
To recognized track of bullet and wound
- When there is pelvic pain ‘ tenderness or other
abnormal finding to recognized pelvic fructure

29. PELVIC TRAUMA

30. SEPTRUM OF ENERGY
 Low energy
Elderly sustaining falls
Sports injuries
 High energy
MVC
MCC
Falls from height

31. MORTALITY
 10-20% overall mortality
 38% mortality if hypotensive on admission
 50% mortality for open injuries
 89% of traumatic aortic transections have
pelvic fractures

32. CLOSE APPOSITION OF VITAL STRUCTURES
 iliac artery and vein
 superior gluteal artery
 bladder/prostate
 rectum/vagina
 sacral plexus

33.  Follow ATLS principles (ABC’S)
 Primary and secondary survey
 Find source of bleeding
 major lacerations
 occult
 chest--CXR
 abdomen--DPL (supraumbilical)/US
 pelvis--AP pelvis

34. PELVIC EXAM
 deformity of pelvis
 leg length difference
 abrasions/swelling over pelvis
 scrotal/labial swelling
 stability--pelvic rock and push pull
 GU--blood at meatus
 rectal exam--perineal tears/prostate position

35. X - RAY
 AP pelvis--adequate initial evaluation for 90-
95% cases

36. X - RAY
 Inlet view--defines AP translation

37. X - RAY
 Outlet view--defines cephalad/caudad
translation

38. CT--BEST VIEW OF POSTERIOR RING

39. CLASSIFICATION SCHEMES
 Young and Burgess--Force Vector
 lateral compression
 antero-posterior
 vertical
 combined
 Tile--Force Vector and Instability Pattern
 stable
 vertically stable/horizontally unstable
 vertically and horizontally unstable

40.  STABLE PELVIC
 UNSTABLE PELVIC

42. LATERAL COMPRESSION
 L-C I and II
 head injury - 44-90%
 shock - 31%

43. L-C I and II
head injury - 44-90%
shock - 31%

44.  L-C III
 bowel injury - 20%
 shock - 40%
 Retroperitoneal hematoma - 60%
 lower extremity fracture - 40%

45. ANTEROPOSTERIOR

46. ANTEROPOSTERIOR
 AP II
 shock - 30%
 ARDS - 10%

47.  Anteroposterior III
 retroperitoneal
hematoma - 60%
 shock - 67%
 ARDS - 18.5%
 death - 37%

48. VERTICAL SHEAR
head injury 56%
lung 23%
spleen 25%
shock 62.5%
mortality 25%

49. SACRAL FRACTURES
Denis I
5.9% nerve injury
Denis II
28.4% nerve injury
Denis III
56.7% nerve injury

50. BLOOD TRANSFUSION REQUIRMENT
 Lateral compression --
3.6u
 anteroposterior
--14.8u
 vertical shear --
9.2u
 combined--8.5u

51. ACUTE STABILIZATION METHODS
 Tied sheet
 Sand bags
 Lateral decubituse positioning
 traction
 MAST Trousers
 Pelvic band
 External Fixation
 Pelvic clamp

52. EXTERNAL FIXIATION VS MAST
 Hemorrhage control
95% vs 71% success
 transfusion
3.7u vs 7.4u pRBC
 mortality (hypotensives)
21% vs 41%
 overall mortality
6% vs 26%
 mortality with closed
head injury
7% vs 43%

53. THANKS