Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007.
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Transcript of Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007.
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Abdominal Abdominal TraumaTrauma
Nestor Nestor, M.D., M.Sc.Nestor Nestor, M.D., M.Sc.
January 17, 2007January 17, 2007
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The PlanThe Plan
Abdominal AnatomyAbdominal Anatomy Mechanisms of Mechanisms of
InjuryInjury Common PathologyCommon Pathology EvaluationEvaluation ManagementManagement
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Part 1:Part 1:Abdominal Abdominal AnatomyAnatomy
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Abdominal Anatomy Abdominal Anatomy BasicsBasics
ABC’sABC’s Many organs receiving substantial Many organs receiving substantial
blood flowblood flow Potential spaces that can hide Potential spaces that can hide
hemorrhagehemorrhage Hollow organ damageHollow organ damage > Peritonitis> Peritonitis
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Abdominal Anatomy Abdominal Anatomy BasicsBasics
ABC’sABC’s Many organs receiving substantial Many organs receiving substantial
blood flowblood flow Potential spaces that can hide Potential spaces that can hide
hemorrhagehemorrhage Hollow organ damageHollow organ damage > Peritonitis> Peritonitis
![Page 6: Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007.](https://reader036.fdocuments.net/reader036/viewer/2022062313/56649c9e5503460f9495eb00/html5/thumbnails/6.jpg)
Abdominal Anatomy Abdominal Anatomy BasicsBasics
ABC’sABC’s Many organs receiving substantial Many organs receiving substantial
blood flowblood flow Potential spaces that can hide Potential spaces that can hide
hemorrhagehemorrhage Hollow organ damage > PeritonitisHollow organ damage > Peritonitis
![Page 7: Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007.](https://reader036.fdocuments.net/reader036/viewer/2022062313/56649c9e5503460f9495eb00/html5/thumbnails/7.jpg)
Abdominal Anatomy Abdominal Anatomy BasicsBasics
ABC’sABC’s Many organs receiving substantial Many organs receiving substantial
blood flowblood flow Potential spaces that can hide Potential spaces that can hide
hemorrhagehemorrhage Hollow organ damage > PeritonitisHollow organ damage > Peritonitis
![Page 8: Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007.](https://reader036.fdocuments.net/reader036/viewer/2022062313/56649c9e5503460f9495eb00/html5/thumbnails/8.jpg)
Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants
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Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants
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Abdominal AnatomyAbdominal Anatomy
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Abdominal AnatomyAbdominal Anatomy
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Abdominal AnatomyAbdominal Anatomy
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Abdominal AnatomyAbdominal Anatomy
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Abdominal Anatomy:Abdominal Anatomy:Four QuadrantsFour Quadrants
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Alternative DivisionsAlternative Divisions
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Intraperitoneal Intraperitoneal StructuresStructures
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Retroperitoneal Retroperitoneal StructuresStructures
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Upper Abdomen CTUpper Abdomen CT
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Lower Abdomen CTLower Abdomen CT
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Retroperitoneal Retroperitoneal
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Part 2:Part 2:Mechanisms andMechanisms and
PathologyPathology
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Abdominal InjuriesAbdominal Injuries
Blunt vs. PenetratingBlunt vs. Penetrating
Often both occur simultaneouslyOften both occur simultaneously
Blunt is the most common Blunt is the most common mechanism in USmechanism in US
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Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or
movement of organsmovement of organs Compressive, stretching Compressive, stretching
or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood
LossLoss Hollow Organs > Blood Hollow Organs > Blood
Loss and Peritoneal Loss and Peritoneal ContaminationContamination
Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially
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Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or
movement of organsmovement of organs Compressive, stretching Compressive, stretching
or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood
LossLoss Hollow Organs > Blood Hollow Organs > Blood
Loss and Peritoneal Loss and Peritoneal ContaminationContamination
Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially
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Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or
movement of organsmovement of organs Compressive, stretching Compressive, stretching
or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood
LossLoss Hollow Organs > Blood Hollow Organs > Blood
Loss and Peritoneal Loss and Peritoneal ContaminationContamination
Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially
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Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or
movement of organsmovement of organs Compressive, stretching Compressive, stretching
or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood
LossLoss Hollow Organs > Blood Hollow Organs > Blood
Loss and Peritoneal Loss and Peritoneal ContaminationContamination
Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially
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Blunt Abdominal TraumaBlunt Abdominal Trauma Direct impact or Direct impact or
movement of organsmovement of organs Compressive, stretching Compressive, stretching
or shearing forcesor shearing forces Solid Organs > Blood Solid Organs > Blood
LossLoss Hollow Organs > Blood Hollow Organs > Blood
Loss and Peritoneal Loss and Peritoneal ContaminationContamination
Retroperitoneal > Often Retroperitoneal > Often asymptomatic initiallyasymptomatic initially
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Liver LacerationsLiver Lacerations
I. I. Subcapsular Hematoma <10% Subcapsular Hematoma <10% Surface AreaSurface Area
II. Subcapsular Hematoma 10-50% II. Subcapsular Hematoma 10-50%
III. Subcapsular Hematoma >50% III. Subcapsular Hematoma >50%
IV. Parenchymal Disruption of 25-75%IV. Parenchymal Disruption of 25-75%
V. Parenchymal Disruption of >75%V. Parenchymal Disruption of >75%
VI. Liver AvulsionVI. Liver Avulsion
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Splenic LacerationsSplenic Lacerations
I. I. Subcapsular Hematoma <10% Subcapsular Hematoma <10% Surface AreaSurface Area
II. Subcapsular Hematoma 10-50% II. Subcapsular Hematoma 10-50%
III. Subcapsular Hematoma >50% III. Subcapsular Hematoma >50%
IV. Laceration producing IV. Laceration producing devascularization of devascularization of >25% of >25% of the spleenthe spleen
V. Shattered SpleenV. Shattered Spleen
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Evaluation: Evaluation: Be SuspiciousBe Suspicious
MechanismMechanism VitalsVitals SymptomsSymptoms Associated InjuriesAssociated Injuries Elderly or co-morbiditiesElderly or co-morbidities Distracting injuriesDistracting injuries Decreased MS/intoxicationDecreased MS/intoxication
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Techniques for Techniques for EvaluationEvaluation
Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and
reliable ptreliable pt
Plain FilmsPlain Films Abd films little or no use, pelvic are the Abd films little or no use, pelvic are the
standardstandard
ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound:Ultrasound: FAST (serial exams)FAST (serial exams)
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Techniques for Techniques for EvaluationEvaluation
Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and
reliable ptreliable pt
Plain FilmsPlain Films Abd films little or no use, pelvis are the Abd films little or no use, pelvis are the
standardstandard
ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound:Ultrasound: FAST (serial exams)FAST (serial exams)
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Techniques for Techniques for EvaluationEvaluation
Physical ExamPhysical Exam Serial exams in awake, alert and Serial exams in awake, alert and
reliable ptreliable pt
Plain FilmsPlain Films Abd films little or no use, pelvis are the Abd films little or no use, pelvis are the
standardstandard
ScreeningScreening Diagnostic Peritoneal Lavage (DPL)Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams)Ultrasound: FAST (serial exams)
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FAST: RUQFAST: RUQ
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FAST: RUQFAST: RUQ
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FAST: RUQFAST: RUQ
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Techniques for Techniques for EvaluationEvaluation
Organ Specific DxOrgan Specific Dx Only CT Only CT Also evaluates retroperitoneumAlso evaluates retroperitoneum ExpensiveExpensive RadiationRadiationEx LapEx Lap Laparotomy gold standard for evaluation Laparotomy gold standard for evaluation Concomitant treatmentConcomitant treatment Retroperitoneum difficult to Retroperitoneum difficult to
explore/assessexplore/assess
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Techniques for Techniques for EvaluationEvaluation
Organ Specific DxOrgan Specific Dx Only CT Only CT Also evaluates retroperitoneumAlso evaluates retroperitoneum ExpensiveExpensive RadiationRadiationEx LapEx Lap Laparotomy is the gold standard for Laparotomy is the gold standard for
evaluation evaluation Concomitant treatmentConcomitant treatment Retroperitoneum difficult to Retroperitoneum difficult to
explore/assessexplore/assess
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Penetrating Trauma Penetrating Trauma EvaluationEvaluation
Mandatory exploration abandonedMandatory exploration abandoned No digital exploration or contrast No digital exploration or contrast
studiesstudies Inspect wound to determine if there Inspect wound to determine if there
is violation of the fasciais violation of the fascia Difficult to assess stab wound Difficult to assess stab wound
trajectorytrajectory Determine if gunshot traversed the Determine if gunshot traversed the
peritoneal cavityperitoneal cavity
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ManagementManagement
ABC’sABC’s Fluid resuscitateFluid resuscitate To lap or not to lap?To lap or not to lap? Unstable (with no other reason)Unstable (with no other reason) Free air/peritonitis (antibiotics)Free air/peritonitis (antibiotics) Unexplained free fluidUnexplained free fluid Many splenic/liver lacs managed Many splenic/liver lacs managed
non-operatively or by VIRnon-operatively or by VIR
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Penetrating Flank and Penetrating Flank and Buttock InjuriesButtock Injuries
Potential for peritoneal Potential for peritoneal and/or retroperitoneal and/or retroperitoneal injuryinjury
Similar evaluation and Similar evaluation and management to management to abdominalabdominal
Buttock injuries may also Buttock injuries may also reach peritoneal and/or reach peritoneal and/or retroperitonal structuresretroperitonal structures
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Genitourinary Genitourinary TraumaTrauma
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GU TraumaGU Trauma
2-5% of adult traumas2-5% of adult traumas Vast majority blunt mechanismsVast majority blunt mechanisms 80% renal injuries80% renal injuries 10% bladder injuries10% bladder injuries Abnormalities (tumor, hydro) Abnormalities (tumor, hydro)
increase susceptibility increase susceptibility Rarely require immediate Rarely require immediate
interventionintervention
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EvaluationEvaluation
Rectal - high riding prostateRectal - high riding prostate Perineum - ecchymosis, lacsPerineum - ecchymosis, lacs Genitals - meatal/vaginal bloodGenitals - meatal/vaginal blood Difficult catheter placement (may Difficult catheter placement (may
need suprapubic)need suprapubic) UA – hematuria (poor correlation to UA – hematuria (poor correlation to
degree of injury)degree of injury)
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EvaluationEvaluation
U/S and Plain films of little useU/S and Plain films of little use CT is the superior imaging modalityCT is the superior imaging modality Careful with contrast (nephropathy)Careful with contrast (nephropathy) Angiography remains the gold Angiography remains the gold
standard standard IVP/Cystoscopy less useful in the EDIVP/Cystoscopy less useful in the ED
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GU Injuries: The KidneysGU Injuries: The Kidneys
Kidneys are well protectedKidneys are well protected Most commonly bruisedMost commonly bruised Pts with a shattered kidney become Pts with a shattered kidney become
rapidly unstablerapidly unstable Renal vascular injuries may result in Renal vascular injuries may result in
thrombosed vesselsthrombosed vessels
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GU Injuries: The KidneysGU Injuries: The Kidneys
Operative management for:Operative management for: uncontrolled hemorrhageuncontrolled hemorrhage Penetrating injuriesPenetrating injuries Multiple lacsMultiple lacs Shattered kidneyShattered kidney Avulsed vesselsAvulsed vessels
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GU Injuries: The BladderGU Injuries: The Bladder
ContusionContusion Rupture: Intra vs. ExtraperitonealRupture: Intra vs. Extraperitoneal Extraperitoneal presents with pain, Extraperitoneal presents with pain,
hematuria and inability to voidhematuria and inability to void Urethral injuries: Anterior vs. Urethral injuries: Anterior vs.
posteriorposterior No Foley for urethral injuriesNo Foley for urethral injuries
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Retroperitoneal Retroperitoneal StructuresStructures
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In Summary...In Summary...
Basic knowledge of anatomy Basic knowledge of anatomy necessary for initial assessment of necessary for initial assessment of abdominal traumaabdominal trauma
Peritoneal vs. RetroperitonealPeritoneal vs. Retroperitoneal Blunt vs. PenetratingBlunt vs. Penetrating Don’t miss GU injuriesDon’t miss GU injuries
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Thank YouThank You