1. PRESENTED BY: Dr Louza Alnqodi, R3
Abdominal trauma
PRESENTED BY:
Dr Louza Alnqodi, R3

2. outlines
Background
Clinical assessment of pt with blunt , penetrating abdominal injuries
Diagnostic tools
Clinical approach
Conclusion.

3. R1 Which of the following does not cause a falsely +ve DPL?
*Abdominal wall hematoma
*inadequate homeostasis
*pelvic #
*retroperitoneal injury

4. R1 Which of the following does not cause a falsely +ve DPL?
*Abdominal wall hematoma
*inadequate haemostasis
*pelvic #
retroperitoneal injury

5. 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

6. 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

7. 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

8. 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

9. R4
All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one?
*bowel protrusion or evisceration
*evidence of diaphragmatic injury
*indeterminate local wound exploration
Peritoneal irritation on physical examination
Significant GI bleeding

10. R4
All of the following are clinical indicators' for urgent laprotomy in pt presenting with abdominal stab wounds except which one?
*bowel protrusion or evisceration
*evidence of diaphragmatic injury
*indeterminate local wound exploration
Peritoneal irritation on physical examination
Significant GI bleeding

11. 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.

12. R5 *evaluation of the peritoneal entry by local wound exploration
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.

13. anatomy Anterior abdomen flank Back intraperitoneal contents
Retroperitoneal space contents
Pelvic cavity contents

14. Anterior abdomen:
trans-nipple line, , anterior axillary lines, inguinal ligaments and symphysis pubis.
flank:
anterior and posterior axillary line ;sixth intercostal to iliac crest
Back:
posterior axillary line; tip of scapula to iliac crest

15. Retroperitoneal space:
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

16. mechanism Blunt trauma: Penetrating injuries. MVC Seatbelt injury
fall from ht
crash injury
sport injury
Penetrating injuries.

17. Blunt abdominal injuries carry a greater risk of morbidity and mortality than peneterating abdominal injuries.

18. associated with severe trauma to multiple intraperitoneal organs and extra-abdominal systems
altered mental status, intoxication
Peritoneal signs are often subtle and may be obscured by other painful injuries
Up to 20% of patients with hemoperitoneum have benign abdominal exams on initial presentation.

19. Blunt injury
Spleen (40-55%) Liver (35-45%) Small bowel (5-10%) Retroperitoneal hematoma: 15%

20. Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE?
 CT scan may confirm injury, but should not delay laparotomy in unstable patients.
 Twenty percent of patients with left lower rib fractures have associated splenic injury.
 Focused Assessment with Sonography for Trauma is useful if performed by experienced users.
 Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.

21. Splenic rupture is the most common visceral injury with blunt abdominal trauma. Which of the following statements regarding splenic rupture is FALSE?
 CT scan may confirm injury, but should not delay laparotomy in unstable patients.
 Twenty percent of patients with left lower rib fractures have associated splenic injury.
 Focused Assessment with Sonography for Trauma is useful if performed by experienced users.
 Signs of peritonitis (involuntary guarding, rigidity, rebound) are nearly always present.

22. 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.

23. pathogensis
compression of bowel between the belt and the vertebral column.
an acute short closed-loop obstruction occurs along with perforation secondary to the sudden generation of high intraluminal pressures.

24. Clinically, two symptom patterns emerge.
~1/4 of pt develop evidence of a hemoperitoneum secondary to mesenteric lacerations.
In the remainder, the intestinal injury most commonly involves the jejunum contusion or perforation.
Rare cases of acute abdominal aortic dissection with incomplete or complete occlusion have also been described, and injuries to the lumbar spine are not uncommon.

25. Penetrating abdominal trauma

26. Mechanism
Stab wound
gunshot

27. Knives are not the sole implement used in stabbings.
Ice picks, pens, coat hangers, screwdrivers, and broken bottles.
most commonly in the upper quadrants, the left more commonly than the right.

28. 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.

29. Gunshot Wounds the degree of injury depends .
handguns, rifles, and shotgun
the degree of injury depends .
amount of kinetic energy imparted by the bullet to the victim
mass of the bullet and the square of its velocity
Distance .

30. Missile velocities : low (slower than 1100ft/sec) medium ( ft/sec) high (faster than ft/sec)

31. type I wounds: long range (>7 yards) , a penetration of subcutaneous tissue and deep fascia only.
Type II wounds: distance of 3 to 7 yards and may create a large number of perforated structures.
Type III wounds occur at point-blank range (<3 yards) and involve a massive destruction of tissue

32. multiple organ injuries are sustained, notably perforations to bowel .
greatest for small bowel, followed by the colon and then the liver.

33. 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

34. Small bowel injury is the most common injury resulting from ___ abdominal trauma.
 penetrating
 blunt

35. Small bowel injury is the most common injury resulting from ___ abdominal trauma.
 penetrating
 blunt

36. CLINICAL ASSESSMENT OF PT WITH ABDOMINAL TRAUMA .

37. 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
Mechanism of injury is an important factor in developing a high index of suspicion; thus a detailed history is helpful if available.

38. Details about accident
Damage to car
Velocity
Steering wheel damage
Type of seatbelts used
Air bags deployed
All patients involved in deceleration injuries and bicycle injuries should be suspected of having intraabdominal injury

39. In penetrating trauma:
# of shots or stabs
Type of weapon
Distance b/w firearm and victim

40. examination
Overall, the accuracy of the physical examination in patients with blunt abdominal trauma is 55% to 65%.
Although the presence of physical findings makes intraperitoneal injury more likely, their absence does not preclude serious pathology, and none is exclusively diagnostic of a specific injury.

41. Hypotension in the acute stage results from hemorrhage that is most often from a solid visceral or vascular injury.
hypotension with significant multiple blunt trauma and is unexplained, one should assume the presence of intraperitoneal hemorrhage until it is excluded.

42. In conscious, alert pt, look for:
Abdo tenderness,90%
Peritoneal irritation
Penetrating: wounds (log roll pt)
Ecchymosis, Cullen and Gray-Turner signs

43. Rectal exam is important; assess for blood and palpable bony fragments and position of the prostate. High riding prostate suggests posterior urethral tears.
Urethral disruption should be considered when blood is noted at the meatus.
Vaginal exam for bleeding – may suggest bony fragments causing laceration. Implications of bleeding during pregnancy should be considered.

44. The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT:
 abdominal pain and tenderness
 early bacterial peritonitis
 development of rebound, guarding and rigidity
 hypotension and tachycardia
 palpable mass and radiographic mass effect (may result from confined hemorrhage)

45. The major findings with injury of the solid abdominal organs are those of hemorrhagic shock. Signs with solid organ injury include all of the following EXCEPT:
 abdominal pain and tenderness
 early bacterial peritonitis
 development of rebound, guarding and rigidity
 hypotension and tachycardia
 palpable mass and radiographic mass effect (may result from confined hemorrhage)

46. 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

47. Are abdo x-rays useful in trauma?
Although plain abdominal films can demonstrate numerous findings, their place in acute trauma is limited. Because of spinal precautions, hemodynamic instability, time consuming or patient discomfort.

49. Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT :
 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 

50. Smaller diaphragmatic injuries are often missed, with herniation occurring late as the negative intrathoracic pressure gradually draws the mobile abdominal organs into the chest. Early radiographic findings may be absent or subtle and include all of the following EXCEPT :
 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 

51. Imaging CT US Able to define organ injury
Good for retroperitoneal & vertebral column
Non-invasive
Not Operator dependant
Not great for hollow viscus
Stable patient
Cost $$$
Complications: IV or oral contrast US
Good for solid organs
Portable
Fast
100 cc detection blood
Mediastinum evaluation
No radiation
No contrast need
Not see well: solid parenchymal, retroperitoneal, diaphragm
Problem if: obesity, gas
Less sensitive than DPL for hemoperitoneal
Operator dependant

52. 20 y/o female patient involved in a low velocity MVA
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 non-operatively.

56. Preferred Site of Diagnostic Peritoneal Lavage
Standard adult :Infraumbilical midline C or SO
Standard pediatric: Infraumbilical midline C or SO
2ed &3ed trimester pregnancy :Suprauterine FO
Midline scarring :Left lower quadrant FO
Pelvic fracture: Supraumbilical FO

57. DPL RBC Criteria (per mm3 )
Indeterminate
Positive
20–100,000
100,000
Blunt
Stab wound
  20,000–100,000
  Anterior abdomen
20,000–100,00
 Flank
20,000–100,000
  Back
5000
Low chest
Gunshot wound

58. List causes false negative DPL?
Catheter preperitoneal space
Fluid in compartment 2 adhesions
Diaphragmatic tear, so fluid goes into thoracic cavity

59. Relative contraindications:
-sole absolute contraindication to DPL is the established need for laparotomy.
Relative contraindications:
prior abdominal surgery
Infections
Coagulopathy
obesity
second- or third-trimester pregnancy.

60. CLINICAL APPROCHES TO PT WITH:
BLUNT ABDOMINAL TRAUMA
STAB WOUND
GUNSHOT
ABDOMINAL WITH PELVIC TRAUMA.

62. Clinical Indications for Laparotomy after Blunt Trauma
Manifestation
Pitfall
Unstable vital signs with strongly suspected abdominal injury
Alternate sources shock
Unequivocal peritoneal irritation
Unreliable
Pneumoperitoneum
Insensitive; may be due to cardiopulmonary source or invasive procedures (diagnostic peritoneal lavage, laparoscopy)
Evidence of diaphragmatic injury
Nonspecific
Significant gastrointestinal bleeding
Uncommon, unknown accuracy

63. Approach to abdominal stab wound.
Step I: Clinical Indications for Laparotomy.
Step II: Peritoneal Violation.
Step III: Injury Requiring Laparotomy.

65. Clinical Indications for Laparotomy Following Penetrating Trauma
Manifestation
Premise
Pitfall
Hemodynamic instability
Major solid visceral or vascular injury
Thorax or mediastinum, causal or contributory
Peritoneal signs
Intraperitoneal injury
Unreliable, especially immediately post-injury
Evisceration
Additional bowel, other injury
No injury in one fourth to one third of stab wound cases
Diaphragmatic injury
Diaphragm
Rare clinical, radiographic findings
Gastrointestinal hemorrhage
Proximal gut
Uncommon, unknown accuracy
Implement in situ
Vascular impalement
Comorbid disease or pregnancy creates high operative risk
Intraperitoneal air
Hollow viscus perforation
Insensitive; may be caused by intraperitoneal entry only or be due to cardiopulmonary source

66. Peritoneal Violation. 1. Evisceration 2. Intraperitoneal air
3.    Local wound exploration
4.    Ultrasonography
5.    Laparoscopy

67. Stab wound to right lower quadrant with caecal evisceration
Stab wound to right lower quadrant with caecal evisceration.  No colon injury at laparotomy.

68. Eviscerated omentum is easily mistaken for subcutaneous fat, so care must be taken in the examination of open abdominal injuries. Which of the following statements regarding abdominal evisceration treatment is FALSE?
 Cover eviscerated organs with moist gauze or petrolatum gauze (to prevent desiccation) for replacement at laparotomy.
 Return all eviscerated organs to the peritoneal cavity. 
 Only organs with vascular compromise should be promptly returned to the abdominal cavity.

69. Eviscerated omentum is easily mistaken for subcutaneous fat, so care must be taken in the examination of open abdominal injuries. Which of the following statements regarding abdominal evisceration treatment is FALSE?
 Cover eviscerated organs with moist gauze or petrolatum gauze (to prevent desiccation) for replacement at laparotomy.
 Return all eviscerated organs to the peritoneal cavity. 
 Only organs with vascular compromise should be promptly returned to the abdominal cavity.

70. In the abdominal stab wound victim without clear indications for exploration (obvious peritoneal penetration, unexplained hypotension, or signs of peritoneal irritation), local wound exploration with local anesthesia should be performed; laparotomy should be performed if the __ is penetrated.
 rectus abdominis muscle 
 posterior rectus sheath 
 transversalis fascia.

71. Abdominal stab wound, with hepatic lesion grade II.
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.
Abdominal stab wound, with hepatic lesion grade II.

72. 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.
exceptions to this practice exist:
situations in which emergency department resuscitation is impeded by the presence of the implement
the patient is at high risk of significant morbidity from nontherapeutic laparotomy because of severe comorbid conditions or pregnancy.

74. What is your approach to pelvic #?

75. 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

76. Ultrasonography and peritoneal aspiration are rapid methods of determining or excluding the presence of hemoperitoneum in the critically ill blunt or penetrating trauma patient.
Clinical indications for laparotomy are more dependable in and more frequently applicable to cases of penetrating trauma than cases of blunt trauma.

77. THANK YOU