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trauma
:PRESENTED BY
Dr Louza Alnqodi, R3
outlines
Background
Clinical assessment of pt with blunt ,
penetrating abdominal injuries
Diagnostic tools
Clinical approach
Conclusion.
R1
Which of the following does not
cause a falsely +ve DPL?
*Abdominal wall hematoma
*inadequate homeostasis
*pelvic #
*retroperitoneal injury
R1
Which of the following does not
cause a falsely +ve DPL?
*Abdominal wall hematoma
*inadequate haemostasis
*pelvic #
retroperitoneal injury
R2
Criteria for a +ve DPL include all
of the following except:
*initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low
chest wound.
*presence of bile, bacteria or meat/vegetable
fibers
R2
Criteria for a +ve DPL include all
of the following except:
initial aspiration of at least 50ml gross blood
*>100,000 RBC in blunt trauma
*>5000 RBC in gunshot or penetrating low
chest wound.
*presence of bile, bacteria or meat/vegetable
fibers
R3
During the evaluation of a trauma
patient, an upright CXR showed
gastric bubble shifted to the rt .
No free air is present. What is the
main concern?
*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury
R3
During the evaluation of a trauma
patient, an upright CXR showed
gastric bubble shifted to the rt .
No free air is present. What is the
main concern?
*bowel perforation
*gastric injury
*retroperitoneal hematoma
*splenic injury
R4
All of the following are clinical
indicators' for urgent laprotomy in pt
presenting with abdominal stab
wounds except which one?
R4
All of the following are clinical
indicators' for urgent laprotomy in pt
presenting with abdominal stab
wounds except which one?
R5
A 25 yr old male presents with a stab
wound to the upper abdomen. Vital signs
are stable. The abdomen is not distended,
soft, non-tender. Bowel sounds are present.
Upright CXR does not demonstrate a
Penumothorax or free air under diaphragm.
What should the next step be?
*evaluation of the peritoneal entry by local wound
exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.
R5
A 25 yr old male presents with a stab wound to
the upper abdomen. Vital signs are stable. The
abdomen is not distended, soft, non-tender.
Bowel sounds are present. Upright CXR does not
demonstrate a Penumothorax or free air under
diaphragm. What should the next step be?
exploration
*performing DPL
*Proceeding directly to Laprotomy
*suturing of the wound and discharging the pt with clear
instruction.
anatomy
Anterior abdomen
flank
Back
intraperitoneal contents
Retroperitoneal space contents
Pelvic cavity contents
o Anterior abdomen:
trans-nipple line, , anterior axillary lines,
inguinal ligaments and symphysis pubis .
o flank:
anterior and posterior axillary line ;sixth
intercostal to iliac crest
o Back:
posterior axillary line; tip of scapula to iliac
crest
Peritoneal cavity:
upper-diaphragm, liver, spleen, stomach, and transverse
colon; lower-small bowel, sigmoid colon
Retroperitoneal space:
aorta, inferior vena cava, duodenum, pancreas, kidneys,
ureters,ascending and descending colons
Pelvic cavity:
rectum, bladder, iliac vessels and internal genitalia
mechanism
Blunt trauma:
MVC
Seatbelt injury
fall from ht
crash injury
sport injury
Penetrating injuries.
Blunt injury
Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Retroperitoneal hematoma: 15%
Seatbelt injuries
Unrestrained front and rear seat passengers are
at unequivocally greater risk of intra-abdominal
injury than their restrained counterparts.
The three-point shoulder-lap belt is the most
effective restraining system and is associated
with the lowest incidence of abdominal injuries.
However, abdominal injuries are still ascribed to
shoulder-lap and lap-belt systems.
pathogensis
o
Penetrating abdominal
trauma
Mechanism
Stab wound
gunshot
Stab wound
multiple in 20% of cases
involve the chest in up to 10% of cases.
Most stab wounds do not cause an
intraperitoneal injury
the incidence varies with the direction of
entry into the peritoneal cavity
The liver, followed by the small bowel, is
the organ most often damaged by stab
wounds.
Gunshot Wounds
handguns, rifles, and shotgun
Missile velocities :
low (slower than 1100ft/sec)
medium (1100-2000ft/sec)
high (faster than 2000-2500ft/sec)
Missiles effects
Extensive tissue damage
external contaminants tend to be dragged
into the wound.
the closure of the tract immediately after
the bullet's passage may lead to an
underestimation of tissue damage.
high-velocity bullets can fragment
internally
CLINICAL ASSESSMENT OF PT
WITH ABDOMINAL TRAUMA .
history
Primary goal is to identify that an injury exists, not
necessarily making an accurate diagnosis.
The patient's history may be unobtainable, elusive,
or temporarily abandoned while resuscitative
measures are carried out.
History from prehospital care team or transferring
hospital : the vital signs, physical assessment,
prehospital course, and response to therapy should
be obtained
In penetrating trauma:
# of shots or stabs
Type of weapon
Distance b/w firearm and victim
examination
DIAGNOSTIC STRATEGIES
Hct: can be a delayed sign, should do serial.
WBC: in stress, peritoneal irritation
Pancreatic enzymes: if normal, does NOT r/o
pancreatic injury
amylase: EtOH, narcotics
amylase & lipase: ischemia 2 hypotension
both non-specific & non-sensitive for
pancreatic injuries
pleural effusion
appearance of the nasogastric tube in the chest
appearance of bowel loops in the chest
elevation of the diaphragm
blurring of the diaphragm
pleural effusion
appearance of the nasogastric tube in the chest
appearance of bowel loops in the chest
elevation of the diaphragm
blurring of the diaphragm
Imaging
CT
Able to define organ
injury
Good for retroperitoneal
& vertebral column
Non-invasive
Not Operator dependant
US
20 y/o female patient involved in a low velocity MVA. Upon initial exam no
abnormalities noted, no complains.
The image shows free fluid in Morrison Pouch. Pt. underwent Abdominal CT
Scan which showed Liver Laceration Grade III. This patient was treated nonoperatively.
Blunt
100,000
Indeterminate
20100,000
Stab wound
Anteriorabdomen
100,000
20,000100,000
Flank
100,000
20,000100,00
Back
100,000
20,000100,000
5000
1000-5000
5000
1000-5000
Low chest
Gunshot wound
CLINICAL APPROCHES TO PT
WITH:
o
o
o
o
Pitfall
Evidence of diaphragmatic
injury
Significant gastrointestinal
bleeding
laparoscopy)
Nonspecific
Uncommon, unknown accuracy
Premise
Pitfall
Hemodynamic instability
Peritoneal signs
Thorax or mediastinum,
causal or contributory
Unreliable, especially
immediately post-injury
Evisceration
Diaphragmatic injury
Diaphragm
Gastrointestinal
hemorrhage
Implement in situ
Proximal gut
Intraperitoneal air
Vascular impalement
Comorbid disease or
pregnancy creates high
operative risk
Insensitive; may be caused by
intraperitoneal entry only or be
due to cardiopulmonary
.Peritoneal Violation
1.
2.
3.
4.
5.
Evisceration
Intraperitoneal air
Local wound exploration
Ultrasonography
Laparoscopy
Stabwoundtorightlowerquadrantwithcaecal
evisceration.Nocoloninjuryatlaparotomy.
25 year male impaled by a five foot iron bar two inches in diameter during a road traffic accident. The bar
entered at the level of the epigastrium and exited through the left posterior thoracic wall.
Implements in situ
implements in situ of the torso in the operating room.
to ensure expeditious control of hemorrhage
the implement reside within a vascular space or highly
vascularized organ.
conculsion
The accuracy of physical examination is limited in
cases of blunt and penetrating trauma. It is less
reliable by distracting injury, altered sensorium
(e.g., head trauma, alcohol or drug intoxication,
mental retardation), and spinal cord injury.
The choice of diagnostic studies for abdominal
trauma is based on clinical need first and
foremost, as well as study availability and the
trustworthiness of that study in a respective
center
THANK YOU