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Snapshot
  • A 30-year-old male victim of an automotive hit-and-run incident presents to the ED. Initial primary survey reveals no airway obstruction and good ventilation. Two large bore IV's are inserted and blood pressure is 95/60 mmHg, pulse is 95/min, respirations are 18/min, and SaO2 is 95% on room air. One liter of Lactated Ringer's is started. Secondary survey reveals no obvious source of blood loss. Despite this and fluid resuscitation, the patient's blood pressure drops to 85/55 mmHg. A FAST ultrasound exam reveals fluid surrounding the spleen and in Morrison's pouch. The patient is rushed to the OR for an exploratory laparotomy.
Introduction
  • Mechanisms of abdominal trauma include blunt and penetrating
    • blunt trauma accounts for 2/3 of all intraabdominal injuries 
      • motor vehicle crash (MVC) is main mode of injury
      • usually causes solid organ injury, but hollow viscus is also usually damaged
        • spleen is most common, liver is second
    • penetrating trauma accounts for 1/3
      • firearms, knives, and other impalers are main modes
      • usually causes hollow organ injury
        • if solid, liver is most common
Presentation
  • Mechanism of injury can create wide spectrum of presentations
    • symptoms and signs of blood loss may not be evident
    • therefore, mechanism of injury can solely determine need for further imaging workup
      • unprotected trauma
        • pedestrian victims of MVC, motorcycle / bicycle crash, assaults with objects
      • high-energy trauma
        • MVC with no restraints, known high speeds, death at scene, substantial vehicular damage
        • falls greater than 15 feet
      • minor trauma in patients with limited reserve to tolerate injury
        • elderly, patients with chronic debilitating disease, immunosuppressed
    • e.g., seatbelt-associated injuries are widespread
      • retroperitoneal duodenal trauma
      • intraperitoneal bowel transection
      • mesenteric injury
      • lumbar spine injury
    • penetrating trauma carries high risk of GI perforation and sepsis

Evaluation

  • Primary and secondary survey
    • physical exam is often unreliable, necessitating serial exams
      • abdomen
        • inspect for contusions, abrasions, seatbelt sign, distention
        • auscultate for bruits, bowel sounds
        • palpate for tenderness, rebound, rigidity, guarding
        • referred pain to shoulder 
        • DRE: rectal tone, blood, bone fragments, prostate location
      • placement of NG tube and Foley catheter
        • NG tube for decompression of stomach and proximal small bowel
          • contraindicated in patients with facial / basal skull fracture
        • Foley catheter for voiding in unconscious patient or patient with multiple injuries who cannot void spontaneously
          • contraindicated if blood at meatus, scrotum is ecchymotic, or prostate is high-riding on DRE
      • remember to assess other systems
  • Imaging
    • FAST ultrasound
      • identifies presence or absence of free fluid in peritoneal, pleural, pericardial cavities rapidly (< 5 minutes)
      • NOT used to identify specific organ injuries
      • if patient has ascites, FAST will be a false positive
    • diagnostic peritoneal lavage (DPL) 
      • rarely used (takes 1 hour)
      • most sensitive test for intraperitoneal blood
        • if > 10 ml gross blood, WBC > 500, amylase > 175, and/or bile/bacterial/foreign material found, DPL is considered positive
      • NOT for retroperitoneal bleed or diaphragmatic rupture
    • CT scan  
      • most specific test
      • significant radiation exposure
      • NOT used if patient is hemodynamically unstable
    • Radiograph
      • can detect free air under diaphragm, hernia, air-fluid levels, fractures
 Management
  • When to obtain imaging in blunt abdominal trauma
    • equivocal abdominal physical exam
    • multiple trauma patient with altered mental status 2/2 head trauma or drugs/alcohol
    • patient with suspected spinal cord injury causing abdominal anesthesia
    • unexplained shock/hypotension
    • fractures of lower ribs, pelvis, spine
  • What imaging to obtain in blunt abdominal trauma
    • start with FAST
      • if positive:
        • hemodynamically (HD) unstable:
          • start IV fluids 
          • go to OR for laparotomy 
        • HD stable: get CT (sometimes CT may be a better initial step depending on the context)
      • if negative:
        • HD unstable: repeat FAST or get DPL
        • but mechanism of injury is significant: get CT
        • if no risk factors: observe with repeat serial physical exams
      • if equivocal:
        • HD unstable: get DPL
        • HD stable: get CT
  • Solid organ injuries in blunt abdominal trauma
    • treat based on hemodynamic stability, not specific injury
      • if unstable, go to OR for laparotomy
      • if stable, spleen/liver/kidney lacerations and hematomas can be graded
        • higher grade portends increased risk of bleeding
          • consider angiography with embolization
  • Hollow viscus injuries in blunt abdominal trauma
    • evidence of perforation (free air in peritoneal cavity)
      • next best step: go to OR for laparotomy
  • Penetrating abdominal trauma
    • if gunshot wound
      • next best step: go to OR for laparotomy
        • any gunshot wound below the nipple line is considered to be abdominal
    • if shock, peritonitis, evisceration, free air in abdomen, or blood in NG/Foley/DRE
      • nest best step: go to OR for laparotomy
  • Retroperitoneal trauma
    • classified and triaged by zones on imaging
      • zone 1 (central)
        • high risk of bleeding from major vessels, pancreas, and duodenum
        • next best step: go to OR for laparotomy
      • zone 2 (perirenal)
        • if stable, next best step: continue to observe
        • if HD unstable or penetrating trauma, first obtain contralateral renal function
          • next best step: go to OR for exploration based on renal function
      • zone 3 (pelvic)
        • first control bleeding with pelvic binder
        • if stable and blunt trauma, no surgical exploration
          • next best step: consider angiography and embolization
        • if unstable and penetrating trauma, surgical exploration may be necessary
Complications
  • Surgical wound infection
    • manage with surgical debridement and broad-spectrum antibiotics 

References

 

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