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Cheryl Pirozzi, MD Fellow’s Conference 5/4/11

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1 Cheryl Pirozzi, MD Fellow’s Conference 5/4/11
Abdominal Trauma Cheryl Pirozzi, MD Fellow’s Conference 5/4/11

2 Abdominal Trauma Penetrating Abdominal Trauma Blunt Abdominal Trauma
Stabbing 3x more common than firearm wounds GSW cause 90% of the deaths Most commonly injured organs: small intestine > colon > liver Blunt Abdominal Trauma Greater mortality than PAT (more difficult to diagnose, commonly associated with trauma to multiple organs/systems) Most commonly injured organs: spleen > liver, intestine is the most likely hollow viscus. Most common causes: MVA ( % of cases) > blows to abdomen (15%) > falls (6 - 9%) Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate Rosen’s Emergency Medicine, 7th ed. 2009

3 Pathophysiology of injury
Penetrating Abdominal Trauma Stab Wounds Knives, ice picks, pens, coat hangers, broken bottles Liver, small bowel, spleen Gunshot wounds small bowel, colon and liver Often multiple organ injuries, bowel perforations Wounds from stabbing implements occur nearly three times more often than wounds from firearms, but the latter have a significantly greater associated mortality rate Rosen’s Emergency Medicine, 7th ed. 2009

4 Pathophysiology of injury
Rosen’s Emergency Medicine, 7th ed. 2009

5 Pathophysiology of injury
Blunt Abdominal Trauma Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures Crushing effect Acceleration and deceleration forces → shear injury Seat belt injuries “seat belt sign” = highly correlated with intraperitoneal injury Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures created by outward forces Lap-belt restraints “seat belt sign” = contusion or abrasion across the lower abdomen, highly correlated with intraperitoneal injury Rosen’s Emergency Medicine, 7th ed. 2009

6 Physical Exam Generally unreliable due to distracting injury, AMS, spinal cord injury Look for signs of intraperitoneal injury abdominal tenderness, peritoneal irritation, gastrointestinal hemorrhage, hypovolemia, hypotension entrance and exit wounds to determine path of injury. Distention - pneumoperitoneum, gastric dilation, or ileus Ecchymosis of flanks (Gray-Turner sign) or umbilicus (Cullen's sign) - retroperitoneal hemorrhage Abdominal contusions – eg lap belts ↓bowel sounds suggests intraperitoneal injuries DRE: blood or subcutaneous emphysema eg lap belts herald abdominal injuries in one third of cases Rosen’s Emergency Medicine, 7th ed. 2009

7 Diagnostic studies Lab tests: not very helpful
May have ↓ Hct, ↑ WBC, lactate, LFTs, lipase, tox screen Rosen’s Emergency Medicine, 7th ed. 2009

8 Imaging Plain films: fractures – nearby visceral damage
free intraperitoneal air Foreign bodies and missiles films in which the patient is in a lateral decubitus position, air is located in the superior flank and outlines the lateral liver edge Demonstration of free intraperitoneal air on left lateral decubitus film. This is the preferred decubitus position because it avoids confusion with the gastric bubble and splenic flexure Erect film demonstrates the soap bubble appearance of retroperitoneal air outlining the right kidney. Duodenal perforation is the responsible pathologic condition Rosen’s Emergency Medicine, 7th ed. 2009

9 Imaging CT Accurate for solid visceral lesions and intraperitoneal hemorrhage guide nonoperative management of solid organ damage IV not oral contrast Disadvantages : insensitive for injury of the pancreas, diaphragm, small bowel, and mesentery Grade 4 splenic laceration Grade 3 right renal laceration (encircled).  CT is particularly helpful in guiding nonoperative management of solid organ damage.[44-46] This includes as-needed follow-up studies of convalescing patients with these injuries. It has also proven effective when incorporated in delayed fashion for patients with decreasing hematocrit, increasing base deficit, or subtle examination changes. By minimizing the incidence of nontherapeutic laparotomies for self-limited injury to the liver or spleen, trauma centers are using CT with intravenous (IV) contrast only, as it has been shown that little additional information is provided by the addition of oral contrast, which delays scanning and may pose an aspiration risk for the patient.[48,49] Rosen’s Emergency Medicine, 7th ed. 2009

10 Imaging Angiography To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable pt Rarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma Angioembolization of splenic laceration. Note coil in the splenic artery (white arrow) and blush representing active hemorrhage stemming from two branches Rosen’s Emergency Medicine, 7th ed. 2009

11 FAST Focused assessment with sonography for trauma (FAST)
To diagnose free intraperitoneal blood after blunt trauma 4 areas: Perihepatic & hepato-renal space (Morrison’s pouch) Perisplenic Pelvis (Pouch of Douglas/rectovesical pouch) Pericardium (subxiphoid) sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid Extended FAST (E-FAST): Add thoracic windows to look for pneumothorax. Sensitivity 59%, specificity up to 99% for PTX (c/w CXR 20%) Dependent portions of the intraperiton when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agentseal cavity where blood is likely to accumulate Rosen’s Emergency Medicine, 7th ed. 2009 Trauma.org

12 FAST Morrison’s pouch (hepato-renal space) trauma.org
Figure 43-8.  A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate Rosen’s Emergency Medicine, 7th ed. 2009

13 FAST Perisplenic view trauma.org
Figure 43-8.  A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate trauma.org Rosen’s Emergency Medicine, 7th ed. 2009

14 FAST Retrovesicle (Pouch of Douglas) Pericardium (subxiphoid)
Figure 43-8.  A. Normal Morrison's pouch view. Note the absence of an anechoic stripe, which would represent a fluid collection between the liver and kidney. B. Positive Morrison's pouch view. Note presence of an anechoic stripe representing a fluid collection between the liver and kidney (solid arrow). C. Positive perisplenic view. Note anechoic fluid around spleen (solid arrows). D. Positive fluid in the sagittal retrovesicle view (arrow). Note anechoic stripe indicative of retroperitoneal fluid. E. Positive transverse retrovesicle view. Note anechoic area indicative of retroperitoneal fluid (arrow). Dependent portions of the intraperitoneal cavity where blood is likely to accumulate trauma.org Rosen’s Emergency Medicine, 7th ed. 2009

15 FAST Advantages: Disadvantages Portable, fast (<5 min),
No radiation or contrast Less expensive Disadvantages Not as good for solid parenchymal damage, retroperitoneum, or diaphragmatic defects. Limited by obesity, substantial bowel gas, and subcut air. Can’t distinguish blood from ascites. high (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture Dependent portions of the intraperitoneal cavity where blood is likely to accumulate when time is precious in the critical patient, the FAST can provide rapid answers to the key question in the decision matrix, which is whether hemoperitoneum is present. Unlike DPL, the FAST can evaluate intrathoracic structures, is noninvasive, and can be performed serially and by multiple technicians. Unlike CT, it is not a potential radiation hazard and does not require administration of contrast agents Newer studies advocate adding sonographic contrast to further delineate solid organ injuries with minimal hemoperitoneum, especially those of the spleen and liver, which might be amenable to nonoperative management.[64-66] Overall, US can serve as an accurate, rapid, and less expensive diagnostic screening tool than DPL or CT.[67-70] Rosen’s Emergency Medicine, 7th ed. 2009

16 Diagnostic Peritoneal Lavage
Largely replaced by FAST and CT In blunt trauma, used to triage pt who is HD unstable and has multiple injuries with an equivocal FAST examination In stab wounds, for immediate dx of hemoperitoneum, determination of intraperitoneal organ injury, and detection of isolated diaphragm injury In GSW, not used much GSW Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds Rosen’s Emergency Medicine, 7th ed. 2009

17 Diagnostic Peritoneal Lavage
1. attempt to aspirate free peritoneal blood >10 mL positive for intraperitoneal injury 2. insert lavage catheter by seldinger, semiopen, or open 3. lavage peritoneal cavity with saline Positive test: In blunt trauma, or stab wound to anterior, flank, or back: RBC count > 100,000/mm3 In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm3 Positive test = specific for intraperitoneal injury With lower chest stab wounds, a positive RBC count of 5000 to 10,000/mm3 should be considered as evidence of diaphragmatic injury. Because of the more serious nature and greater likelihood of an injury with abdominal gunshot wounds Rosen’s Emergency Medicine, 7th ed. 2009

18 Local Wound Exploration
To determine the depth of penetration in stab wounds If peritoneum is violated, must do more diagnostics Prep, extend wound, carefully examine (No blind probing) Indicated for anterior abdominal stab wounds, less clear for other areas (many do not reach the peritoneum) If LWE indicates that the peritoneum is violated, further diagnostics are indicated. When the stab wound is documented to be superficial to the abdominal cavity, the patient can be safely discharged home after appropriate wound care.[85] Other areas: like back, flank, chest Rosen’s Emergency Medicine, 7th ed. 2009

19 Laparoscopy Most useful to eval penetrating wounds to thoracoabdominal region in stable pt esp for diaphragm injury: Sens 87.5%, specificity 100% Can repair organs via the laparoscope diaphragm, solid viscera, stomach, small bowel. Disadvantages: poor sensitivity for hollow visceral injury, retroperitoneum Complications from trocar misplacement. If diaphragm injury, PTX during insufflation Rosen’s Emergency Medicine, 7th ed. 2009

20 Management General trauma principles:
airway management, 2 large bore IVs, cover penetrating wounds and eviscerations with sterile dressings Prophylactic antibiotics: decrease risk of intra-abdominal sepsis due to intestinal perf/spillage (eg zosyn g IV) In general, leave foreign bodies in and remove in the OR This is considered safest in the event that the implement is intravascular or in a highly vascularized organ.The accuracy of physical examination is limited in cases of blunt and penetrating trauma. It is rendered less reliable by distracting injury, altered sensorium (e.g., head trauma, alcohol or drug intoxication, mental retardation), and spinal cord injury. intestinal perf/spillage can occur afger blunt or PAT Cover anaerobes Rosen’s Emergency Medicine, 7th ed. 2009

21 Management of penetrating abdominal trauma
forsurenot.com

22 Management of penetrating abdominal trauma
Mandatory laparotomy vs Selective nonoperative management Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

23 Management of penetrating abdominal trauma
Mandatory laparotomy standard of care for abdominal stab wounds until 1960s, for GSWs until recently Now thought unnecessary in 70% of abdominal stab wounds Increased complication rates, length of stay, costs Immediate laparotomy indicated for shock, evisceration, and peritonitis Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

24 Management of penetrating abdominal trauma
Selective management used to reduce unnecessary laparotomies Diagnostic studies to determine if there is intraperitoneal injury requiring operative repair Strategy depends on abdominal region: Thoracoabdomen Nipple line to costal margin Anterior abdomen Xiphoid to pubis Flank and back Posterior to anterior axillary line Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

25 Management of penetrating abdominal trauma
Thoracoabdomen Big concern is diaphragmatic injury 7% of thoracoabdominal wounds Diagnostic evaluation: CXR (hemothorax or pneumothorax) Diagnostic peritoneal lavage FAST Thoracoscopy DPL The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injury Even a single stab wound to the low chest can violate the mediastinum, thoracic cavity, diaphragm, peritoneal cavity, and retroperitoneum. The risk of diaphragmatic penetration from a left thoracoabdominal stab wound has been measured at 17%.[86] When all thoracoabdominal wounds are considered, the risk of occult injury is 7%.[100] US can be extremely useful in quickly assessing for hemopericardium and hemoperitoneum in the marginally stable patient when thoracotomy or laparotomy is not already clinically indicated.[106] LWE of slash-type wounds may obviate the need for further evaluation. However, the depth of investigation cannot be taken beyond the anterior rib margin to maximize safety and accuracy. Further assessment for intraperitoneal and diaphragmatic injury can be made by DPL. The RBC criterion is lowered to 5000 to 10,000/mm3 to optimize sensitivity for isolated diaphragmatic injury.[77] Laparoscopy or thoracoscopy can visualize and potentially repair the diaphragm and other organs. Newer multidetector CT and MRI show promise in excluding diaphragmatic injury. CT has a sensitivity of 94% and specificity of almost 96% for detecting diaphragmatic injury. However, equivocal scans must be followed up with more definitive management, including DPL or exploratory laparotomy.[105] A very conservative approach to the left lower chest stab wound, in particular, is mandatory exploration. This approach avoids any opportunity for missed diaphragmatic rents and their delayed consequences but results in an exceptionally high incidence of nontherapeutic operation. Rapid-slice helical CT or MRI may provide a solution to this vexing concern, but data are limited to date. Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

26 Thoracoabdomen Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

27 Management of penetrating abdominal trauma
Anterior abdomen Only 50-70% of anterior stab wounds enter the abdomen of these, only 50-70% cause injury requiring OR 1. is immediate lap indicated ? 2. Has peritoneal cavity been violated? 3. Is laparotomy required? Due to low incidence of intraperitoneal injuries, selective management is well accepted Ask these 3 questions… algorithm Immed lap for Hemodynamic compromise, peritoneal signs, evisceration, Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

28 Management of PAT Anterior abdomen
Clinical mandate = shock, evisceration, peritonitis Rosen’s Emergency Medicine 7th ed

29 Management of penetrating abdominal trauma
Back/Flank Risk of retroperitoneal injury Intraperitoneal organ injury 15-40% Difficulty evaluating retroperitoneal organs with exam and FAST In stable pts, CT scan is reliable for excluding significant injury: Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16:

30 Management of penetrating abdominal trauma
Gunshot wounds Much higher mortality than stab wounds Over 90% of pts with peritoneal penetration have injury requiring operative management Most centers proceed to lap if peritoneal entry is suspected Expectant management rarely done However, the risk of mortality is significantly greater, especially if vascular structures are involved. Missiles striking the low chest commonly penetrate both intrathoracic and abdominal structures, including the diaphragm Biffl et al. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16: Rosen’s Emergency Medicine 2009

31 Management of PAT Gunshot wounds
assess peritoneal entry by missile path, LWE, CT, US, laparoscopy (all limited) Figure   Abdominal gunshot wound algorithm. *Can be assessed by missile path, plain films, local wound exploration, ultrasonography (US), and laparoscopy (LAP). †Most centers proceed to LAP if peritoneal entry is suspected. ‡Patients with documented superficial and low-velocity injuries can be discharged; unknown-depth or high-velocity injuries require further tests or observation. ?Computed tomography (CT), diagnostic peritoneal lavage (DPL), laparoscopy (LPY), or serial physical examinations (SPEs) can be used in singular or complementary fashion depending on the clinical scenario. ?Expectant management of injuries caused by gunshot wounds is rarely attempted. Rosen’s Emergency Medicine, 7th ed. 2009

32 Management of Blunt abdominal trauma
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33 Management of Blunt abdominal trauma
Exam less reliable Diagnostic studies to determine if there is hemoperitoneum or organ injury requiring surgical repair FAST, CT, DPL In HD stable pts, CT is preferred Rosen’s Emergency Medicine, 7th ed. 2009

34 Management of Blunt abdominal trauma
Clinical Indications for Laparotomy after Blunt Trauma MANIFESTATION PITFALL Unstable vital signs with strongly indicated abdominal injury Alternative 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 Rosen’s Emergency Medicine, 7th ed. 2009

35 Damage Control Patients with major exsanguinating injuries may not survive complex procedures Control hemorrhage and contamination with abbreviated laparotomy followed by resuscitation prior to definitive repair For more extensive abdominal trauma, a central concept is that of damage control Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med :S

36 Damage Control 0. initial resuscitation
1. Control of hemorrhage and contamination Control injured vasculature, bleeding solid organs Abdominal packing 2. back to the ICU for resuscitation Correction of hypothermia, acidosis, coagulopathy 3. Definitive repair of injuries 4. Definitive closure of the abdomen Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med :S

37 Damage Control When would you use the damage control strategy? Essentially if the pt is really sick Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med :S

38 Damage Control Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med :S

39 Damage Control Resuscitation in the ICU IVF (crystalloid, not colloid)
Transfusion ?1:1:1 PRBC/plt/FFP Recombinant activated factor VII Increased thromboembolic complications Rewarming if hypothermic Correction of metabolic abnormalities Low tidal volume ventilation recommended (4-6 ml/kg) These are all big topics, about general ICU management but management in the ICU involves: The best transfusion protocol is debated.. NEJM eval of off-label, prospective clinical trials -> increased arterial thromboembolic complications with rfvii Low tidal volume ventilation- extrapolation from ards studies Critical care med 2004 retrospective cohort study- found association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med :S

40 Damage Control Open abdominal wounds and definitive closure
40-70% can’t have primary closure after definitive repair. Temporary closure methods The best transfusion protocol is debated.. Low tidal volume ventilation Waibel et al. Damage control in trauma and abdominal sepsis. Crit Care Med :S

41 Abdominal Compartment Syndrome
Common problem with abdominal trauma Definition: elevated intraabdominal pressure (IAP) of ≥20 mm Hg, with single or multiple organ system failure ± APP below 50 mm Hg Primary ACS: associated with injury/disease in abdomen Secondary (“medical”) ACS: due to problems outside the abdomen (eg sepsis, capillary leak) Major complication of abdominal trauma APP = MAP - IAP Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:

42 Abdominal Compartment Syndrome
Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29

43 Abdominal Compartment Syndrome
Effects of elevated IAP Renal dysfunction Decreased cardiac output Increased airway pressures and decreased compliance Visceral hypoperfusion Can lead to significant reduced lung volumes, impaired gas exchange, high ventilatory pressures. Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:

44 Abdominal Compartment Syndrome
Management Surgical abdominal decompression Nonsurgical: paracentesis, NGT, sedation Staged approach to abdominal repair Temporary abdominal closure Bailey J. Crit Care 2000, 4:23–29 Sugrue M. Curr Opin Crit Care 2005; 11:

45 Conclusions Watch out for implements and missiles violating the abdomen Laparotomy is mandatory if shock, evisceration, or peritonitis Diagnostic studies used to determine need for laparotomy in PAT and BAT FAST is noninvasive, quick and accurate way to evaluate for intraperitoneal blood Damage Control is a principle of staged operative management with control and resuscitation prior to definitive repair Abdominal compartment syndrome is a common problem in abdominal trauma

46

47 References Biffl WL, Moore EE. Management guidelines for penetrating abdominal trauma. Curr Opin Crit Care 2010;16: Waibel BH, Rotondo MF. Damage control in trauma and abdominal sepsis. Crit Care Med Sep;38(9 Suppl):S Marx: Rosen’s Emergency Medicine, 7th ed Mosby Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11: Bailey J, Shapiro M. Abdominal compartment syndrome. Crit Care 2000, 4:23–29


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