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Blunt Abdominal Trauma. Jen Nicol PGY-2 Dr. Rob Lafreniere August 5 th , 2010. Objectives. Physical Exam in BAT 3 important diagnostic modalities Management goals in BAT Hematuria in BAT Common pitfalls. Objectives. Physical Exam in BAT. Accuracy of physical exam in BAT is 55-65%.
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Blunt Abdominal Trauma Jen Nicol PGY-2 Dr. Rob Lafreniere August 5th, 2010
Objectives • Physical Exam in BAT • 3 important diagnostic modalities • Management goals in BAT • Hematuria in BAT • Common pitfalls
Objectives • Physical Exam in BAT
In the alert patient • Pain • Tenderness with guarding • Peritoneal findings • High index of suspicion
Unreliable Findings • Equivocal exam • +/- normal physical exam
Mesentery injury • Bowel perforation, contusion • Rib & spine fractures • Diaphragm injury (rare) Big Badness!
Most common L1-3 50% con-current abdominal injuries
Objectives • 3 important diagnostic modalities
If we all had these..... It would be easy
Negative FAST Pain Hematuria Decreasing hematocrit levels
Established need for laparotomy Prior abdominal surgery Infection Obesity Coagulopathy 2/3rd trimester pregnancy
Positive DPL In BAT: >10 mL aspirated blood >100,000 RBC on lavage Lavage output thorughfoley or chest tube 20,000-100,000 RBC indeterminite in BAT
Objectives • Management goals in BAT
Management Goals: Stabilize the patient Determine presence of intraperitonealhemorrhage Demonstrate organ injury requiring operative intervention Don’t miss injuries!
Clinical Indications for laparotomy in BAT Unstable VS, strongly suggestive abdominal injures Unequivocal peritoneal irritation Evidence of diaphragmatic injury Significant GI bleeding
BAT Yes Clinical Indication for laparotomy No Hemodynamically Unstable? Yes IPH? +ve FAST / DPL IP injury? Source of bleeding? Laparotomy CT scan, FAST, DPL Observe
BAT Clinical Indication for laparotomy No Hemodynamically Unstable? No IPH? IP injury? Other serious injuries Reliable exam Abdominal tenderness
Case 1 50 yo M rolled his dump truck while intoxicated Prolonged extrication – 2 hrs+ Intubated for low GCS, STARS to FMC
78/48; 125; SaO2 96% 100%FiO2; temp 36.4; FAST indeterminite VBG pH 7.26, hbg90, lactate 3.5 ↑ PTT/INR, low plts
No intra-abdominal hemorrhage, no hemothorax Massive bleeding, exanguinating hematoma posterior torso.
Transfused copious amounts blood products To interventional radiology Arrests, dies on table
Case 2 35 yo roofer falls of a 12 ft roof at work. 2min LOC, confused and disoriented, GCS 13 (E3V4M6).
90 palp; HR 86; SaO2 100%2L; RR 18; temp 36.9 abdomen firm, mildly tender LUQ
Embolization by interventional radiology Stabilises, no further transfusions Unit 71, discharged a few days later
Case 3 4 yo F jumped out 2 story window No VS abnormalities Obviously deformed right femur No abdominal tenderness