Trauma– Blunt Abdominal Trauma

Douglas M. Maurer, DO, MPH

Learning Objectives

• Recognize and respond appropriately to a patient with hemorrhagic shock

• Assess via bedside methods the source of hemorrhage

• Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition

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.

Recognition of Hemorrhagic Shock

• Shock: oxygen delivery < tissue demands• Treatment must restore tissue perfusion not just

blood pressure• Shock does NOT SBP < 90mmHg• Recognition includes: mechanism of injury,

patient’s appearance, vitals, level of mentation, peripheral perfusion and urine output

• Clinical parameters should be coupled with objective markers of tissue perfusion--serum lactate, base deficit, etc.

Practical Diagnosis of Shock

• Perform a targeted physical examination • Diagnostic testing should include chest

radiography, pelvis radiography, and bedside ultrasound

• Objective serum makers of tissue perfusion (serum lactate or base deficit)

• Point of care H/H, send CBC, type/cross• DON’T delay resuscitation for lab results

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.

Treatment of Hemorrhagic Shock

• Obtain immediate type and crossmatch for 6-8 units of blood

• Massive transfusion defined as > 10 U of PRBCs in 24 hrs

• Consider use of PRBC to platelet to FFP ratio of 1:1:1 • May result in decreased need for blood

products• Give calcium to prevent citrate toxicity 

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.

FAST Facts

• Reliably identifies 200-250ml of intraperitoneal fluid

• Cannot reliably evaluate retroperitoneum/hollow viscous injury

• Sensitivity/specificity: 75%/98%, NPV: 94%; 86-97% accurate

• Performed using a curvilinear 2.5 or 3.5 MHz probe

FAST Views

• Cardiac: 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).

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”.

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!

Indications for Emergency Laparotomy

• Peritonism• Free air under the diaphragm• Significant gastrointestinal hemorrhage• Hypotension with + FAST scan or + DPA • Do NOT keep trauma patients if you lack

resources to care for them!

Summary

• Recognize and treat hemorrhagic shock aggressively with blood products

• Assess for hemorrhage with bedside methods: CXR, pelvis, and FAST

• Unstable patient: + FAST = OR.• Stable pt: + FAST = abdominal CT.• Stable pt, low mechanism of injury:

- FAST = observation, serial exams.

References

1. Puskarich MA. Initial evaluation and management of blunt abdominal trauma in adults. In: UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012.

2. Nickson C. “Trauma! Blunt abdominal trauma decision making.” Weblog entry. Life in the Fastlane Blog. http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/

3. Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma. 2010 Edition. Chicago, IL. http://www.east.org/resources/treatment-guidelines/category/trauma

4. American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.

Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma

Douglas M. Maurer, DO, MPH, FAAFP

CRITICAL ACTIONS ME NI M SUSTAIN IMPROVE

Completes Primary Survey: recognizes shock

MK2

Safety net – IV, oxygen, monitors (2 x 16G IV)

MK2

Completes Secondary Survey: recognizes abdominal source

MK2

Completes bedside FAST(+ Morrison’s Pouch)

PC5

Recognizes positive FAST: calls surgery

PC5

Bedside labs: POC CBC, lactate, BAL, VBG, blood type/screen/X-match

MK2

Bedside rads: port chest, lat C-spine, AP pelvis

MK2

Gives emergency release blood transfusion

MK2

If unstable: no CT, to ORIf stabilizes: CT, then OR

MK2

TOTAL SBP4

SCENARIO ALGORITHM

SET UP:“Rural” ER Simulated Room

Bedside US and/or FAST simulatorReal patient with simulated skin/abdomen

PRE ARRIVAL:FP in rural ER, lab, rad, OR

35 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 15

ARRIVAL:Full spinal precautions, has 1 IV in place. Pt

awake, alert, conversing, but in mild distress, no meds, no allergies, no sig PMHx or PSHx

PRIMARY SURVEY:A – talking initially, then somnolent B – labored, RR 24, nl breath sounds

C – BP 85/40, HR 130, cool extremitiesD – GCS 14, somnolent, oriented to person

when responds to voiceE – no other trauma, mild abd distension,

hypoactive BS

SECONDARY SURVEY:Other exam normal, c-spine non tender,

pelvis stable, rectal guaiac negativeAbdominal exam tense, tender, absent BS

LABS & IMAGES:Chest, c-spine, pelvis negative

Labs – WBC 9, H/H 8/24, platelets 150, lactate 4, VBG: 7.35/46/40/50%/-8

Positive FAST in RUQ, no CT indicatedBlood type and screen/X-match

DISPOSITION:Must transfuse blood , call Surgeon and direct

to OR, otherwise pt dies of hemorrhage

Simulation Training Assessment Tool (STAT)– Blunt Abdominal TraumaDate: 1 May 2013 Instructor(s): Clark, Maurer, Cuda Learner(s):

Learning 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.

ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)

http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/

Perihepatic

Perihepatic

Perisplenic

Perisplenic

Pelvic

Pelvic

Pericardium

Pericardium