Presentation on theme: "Trauma– Blunt Abdominal Trauma"— Presentation transcript:
1 Trauma– Blunt Abdominal Trauma Douglas M. Maurer, DO, MPH
2 Learning ObjectivesRecognize and respond appropriately to a patient with hemorrhagic shockAssess via bedside methods the source of hemorrhageRespond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition
3 Introduction Blunt abdominal trauma is common. Unknown history, distracting injuries, and altered mental status make these patients difficult to diagnose and manage.Victims frequently have both abdominal and extraabdominal injuries.Family physicians need to be able to recognize and treat hemorrhagic shock.
4 Recognition of Hemorrhagic Shock Shock: oxygen delivery < tissue demandsTreatment must restore tissue perfusion not just blood pressureShock does NOT SBP < 90mmHgRecognition includes: mechanism of injury, patient’s appearance, vitals, level of mentation, peripheral perfusion and urine outputClinical parameters should be coupled with objective markers of tissue perfusion--serum lactate, base deficit, etc.
5 Practical Diagnosis of Shock Perform a targeted physical examinationDiagnostic testing should include chest radiography, pelvis radiography, and bedside ultrasoundObjective serum makers of tissue perfusion (serum lactate or base deficit)Point of care H/H, send CBC, type/crossDON’T delay resuscitation for lab results
6 6 Steps to Treat Hemorrhagic Shock Step 1: Effectively manage the airway and optimize oxygenation.Step 2: Identify and control immediate threats to central perfusion.Step 3: Identify and address severe intracranial injuries.Step 4: Identify and control other potentially life-threatening thoracic and abdominal injuries.Step 5: Identify and control potentially limb-threatening injuries.Step 6: Identify and treat noncritical injuries.
7 Treatment of Hemorrhagic Shock Obtain immediate type and crossmatch for 6-8 units of bloodMassive transfusion defined as > 10 U of PRBCs in 24 hrsConsider use of PRBC to platelet to FFP ratio of 1:1:1May result in decreased need for blood productsGive calcium to prevent citrate toxicity
8 Assessing for Sources of Hemorrhage Chest radiography:Tension pneumothorax? Massive hemothorax? Aortic injury?Pelvis radiography:Pelvic ring disruption?Focused Assessment with Sonography for Trauma (FAST):Pneumo/hemothorax? Hemopericardium? Hemoperitoneum?If positive, then emergency laparotomy.If negative, continue resuscitation, treat other causes.
9 FAST Facts Reliably identifies 200-250ml of intraperitoneal fluid Cannot reliably evaluate retroperitoneum/hollow viscous injurySensitivity/specificity: 75%/98%, NPV: 94%; 86-97% accuratePerformed using a curvilinear 2.5 or 3.5 MHz probeincreased sens/spec with serial examsset gain so fluid in heart is black
10 FAST ViewsCardiac: parasternal or subxiphoid, hepatocardiac interface, pericardial space.RUQ: hepatorenal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney.LUQ: splenorenal interface, diaphragm, inferior pole of kidney, inferior tip of spleen.Suprapubic: outline of bladder, silhouette of uterus (females).4 main views to obtain (stand at pt’s right)Cardiac (probe indicator to pt’s right): parasternal or subxiphoid, hepatocardiac interface, cardiac wall motion, pericardial spaceRUQ (probe indicator cephalad, mid-axillary line, 11/12th ribs): hepatorenal interface (Morrison’s Pouch), diaphragm, inferior pole of kidneyLUQ (probe indicator cephalad, mid-axillary line, 10/11th ribs): splenorenal interface, diaphragm, inferior pole of kidney, inferior tip of spleenSuprapubic (probe indicator to pt’s right, just cephalad to pubic bone): outline of bladder, silhouette of uterus (females)
11 FAST Algorithm Unstable patient: + FAST = OR. Stable pt: + FAST = abdominal CT.Stable pt, low mechanism of injury:- FAST = observation, serial exams.CT is the “Gold Standard”.CT far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. CT is the Gold Standard
12 What About Diagnostic Peritoneal Aspiration (DPA)? Can be performed if - FAST in blunt abdominal trauma.If DPA +, then emergency laparotomy.If DPA -, then seek and treat other sources.Perform serial abdominal exams.Perform serial FAST exams.If patient stabilizes, then CT.Get surgery involved!
13 Indications for Emergency Laparotomy PeritonismFree air under the diaphragmSignificant gastrointestinal hemorrhageHypotension with + FAST scan or + DPA Do NOT keep trauma patients if you lack resources to care for them!**Persistent or recurrent hypotension in the patient with hemoperitoneum is an indication for immediate laparotomy.If patient is hemodynamically stable, then options include:Serial physical examinations +/- FAST scans and observation. CT abdomen with IV contrast (DPL is an alternative if CT abdomen is not available) The choice depends on various factors: availability of imaging; availability of experienced staff to perform serial examinations; patient preference following informed consent; presence of other indications for definitive imaging e.g. seat belt sign, suspected retroperitoneal injury, etc. CT abdomen is primarily used in a hemodynamically stable to identify intraperitoneal injuries in the absence of significant hemorrhage. FAST scan can detect 250 mL of intraperitoneal free fluid, depending on the operator. As such it is useful for identifying significant intraperitoneal hemorrhage. However, ultrasound is not reliable for identifying specific organ injuries or minor hemorrhage.** An important point is that if the above discussed radiographic modalities and/or general surgeon experienced in the care of trauma are not available in your institution, then the patient must be transferred. Do not keep sick trauma patients if you do not have the resources to care for them. An important take home is that if these aren’t available in your institution (including a surgeon who can do something about it), then the patient needs to be transferred. Don’t keep sick trauma patients if you don’t have resources to take care of them
14 SummaryRecognize and treat hemorrhagic shock aggressively with blood productsAssess for hemorrhage with bedside methods: CXR, pelvis, and FASTUnstable patient: + FAST = OR.Stable pt: + FAST = abdominal CT.Stable pt, low mechanism of injury:- FAST = observation, serial exams.
15 ReferencesPuskarich MA. Initial evaluation and management of blunt abdominal trauma in adults. In: UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012.Nickson C. “Trauma! Blunt abdominal trauma decision making.” Weblog entry. Life in the Fastlane Blog.Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma Edition. Chicago, IL.American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.
16 Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma Douglas M. Maurer, DO, MPH, FAAFP
17 Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma Date: 1 May 2013Instructor(s): Clark, Maurer, CudaLearner(s):SCENARIO ALGORITHMSET UP:“Rural” ER Simulated RoomBedside US and/or FAST simulatorReal patient with simulated skin/abdomenPRE ARRIVAL:FP in rural ER, lab, rad, OR35 y/o male s/p unrestrained driver MVA arrives via EMS, in c-collar. VS BP 90/50, HR 110, RR 18, SpO2 97% on RA, GCS 15ARRIVAL:Full spinal precautions, has 1 IV in place. Pt awake, alert, conversing, but in mild distress, no meds, no allergies, no sig PMHx or PSHxPRIMARY SURVEY:A – talking initially, then somnolentB – labored, RR 24, nl breath soundsC – BP 85/40, HR 130, cool extremitiesD – GCS 14, somnolent, oriented to person when responds to voiceE – no other trauma, mild abd distension, hypoactive BSSECONDARY SURVEY:Other exam normal, c-spine non tender, pelvis stable, rectal guaiac negativeAbdominal exam tense, tender, absent BSLABS & IMAGES:Chest, c-spine, pelvis negativeLabs – WBC 9, H/H 8/24, platelets 150, lactate 4, VBG: 7.35/46/40/50%/-8Positive FAST in RUQ, no CT indicatedBlood type and screen/X-matchDISPOSITION:Must transfuse blood , call Surgeon and direct to OR, otherwise pt dies of hemorrhageLearning Objectives:1. Recognize and respond appropriately to a patient with hemorrhagic shock.2. Assess via bedside methods the source of hemorrhage.3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition.CRITICAL ACTIONSMENIMSUSTAINIMPROVECompletes Primary Survey: recognizes shockMK2Safety net – IV, oxygen, monitors (2 x 16G IV)Completes Secondary Survey: recognizes abdominal sourceCompletes bedside FAST(+ Morrison’s Pouch)PC5Recognizes positive FAST: calls surgeryBedside labs: POC CBC, lactate, BAL, VBG, blood type/screen/X-matchBedside rads: port chest, lat C-spine, AP pelvisGives emergency release blood transfusionIf unstable: no CT, to ORIf stabilizes: CT, then ORTOTALSBP4ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)
19 PerihepaticThis photo outlines the normal anatomy one should see on the perihepatic viewNote the: liver, kidney and diaphragmBlood/free fluid would be b/t the liver capsule and renal fasciaIf really good may be able to note liver/renal lacerations, diaphragmatic herniations
20 PerihepaticThis photo shows an abnormal fluid/blood collection b/t the liver and kidney
21 PerisplenicThis photo shows the NORMAL anatomy seen on the perisplenic viewNote the: spleen, kidney, rib shadows—something you will frequently see when you scan both upper quadrants
22 PerisplenicABNORMAL perisplenic scan c free fluid collection b/t spleen and kidney as well as in pericolic gutter
23 Pelvic Pelvic scan with normal anatomy Note the bladder, and rectus abdominus muscle
24 PelvicAbnormal pelvic scan showing blood/fluid collection below the bladder
25 Pericardium Photo showing normal anatomy during a pericardial scan Note the: rib shadowing, liver, diaphragm, ventricles—cannot see any abnormal fluid in the potential space of the pericardium
26 PericardiumAbnormal pericardial scan showing large pericardial fluid collection in trauma pt c cardiac tamponade