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Abdominal and Genitourinary Trauma

Abdominal and Genitourinary Trauma. Steve Lan September 25, 2003. Abdominal Trauma. Anatomy History/Examination Investigations Blunt Trauma Penetrating Trauma. Principles. Two questions: Who needs an OR? How fast do they need it? Focus of history, physical exam and investigations .

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Abdominal and Genitourinary Trauma

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  1. Abdominal and Genitourinary Trauma Steve Lan September 25, 2003

  2. Abdominal Trauma • Anatomy • History/Examination • Investigations • Blunt Trauma • Penetrating Trauma

  3. Principles • Two questions: • Who needs an OR? • How fast do they need it? • Focus of history, physical exam and investigations

  4. Ouch…

  5. Anatomy

  6. Anatomy

  7. Anatomy

  8. History • ABCDE’s • Often limited but focus on mechanism • Blunt vs penetrating • Associated injuries • Radiation of pain – • Scapula – irritation of hemidiaphragm • Testicle – irritation of retroperitoneum

  9. Physical • Vitals • Soft/rigid/distension, bowel sounds • Turner’s (flank bruising), Cullen’s (bruising around umbilicus) **takes 12h – several days to show • Entry/exit wounds • Rectal • Serial exams

  10. Case #1 • 30 yo male, PMHx – 0 • MVA - Head on collision, 60 km/h • No air bags, lap belt • What type of abdo injury is this?

  11. Abdominal TraumaBlunt

  12. Blunt Abdominal Trauma • Greater mortality than penetrating • Occult injuries and associated with other trauma • Difficult to assess • ?history • Altered LOC • Other injuries • Etc.

  13. Blunt Abdominal TraumaPathophysiology • Sudden increase in pressure – rupture or burst within hollow viscus • Compression of visera from anterior force and posterior vertebral body – crush injury • Shearing of organs and vascular pedicles to tear

  14. Blunt Abdominal TraumaPathophysiology • Seatbelt injury • 3 point better than lap belt • Compression of bowel between belt and vertebral column • Spectrum of presentation • mild symptoms to hemoperitoneum • Seatbelt sign • Contusion across lower abdo • Specific but poor sensitivity (<33%)

  15. Blunt Abdominal Trauma • Incidence of organ injury

  16. Case #1 continues • BP 124/60, HR 95, RR 14, Sats 94% on 3L • Intubated for GCS of 9, pt in collar • Abdo exam • Mild abrasion to LUQ/flank • No Cullen’s or Gray-Turners Mild distension, decreased bowel sounds • Does he need a rectal?

  17. “Fingers and tubes in every orifice” “The only reason not to do a rectal, is if there is no rectum or if you don’t have a finger” Hmmm???

  18. DRE in Trauma? • Rosen’s: yes, to look for gross blood, sub-Q emphysema • Prospective observational study, Level II trauma center • 432 pts • 99% normal prostate, 5.2% • FOB + (no change in Rx), • 0.7% gross blood (penetrating injury), • tone normal in 96%, decreased in 4% Porter, J. Ursic, C. Digital Rectal Examination for Trauma: Does Every Patient Need One? The American Surgeon. 2001; 5: 438-441.

  19. DRE in Trauma? • Changed management in 1.2% (5 cases) • Suggest DRE in • Penetrating injury • ?spinal cord injury • “severe” pelvic # Porter, J. Ursic, C. Digital Rectal Examination for Trauma: Does Every Patient Need One? The American Surgeon. 2001; 5: 438-441.

  20. Case #1 – laparotomy? • Clinically (Rosen’s) • Unexplained hypotension • Peritoneal irritation • Radiologic evidence of pneumoperitoneum • Evidence of diaphragm rupture • Persistent GI bleed (NG, vomit, rectal)

  21. Case #1 – Further Investigations • “What labs do you want doctor?”

  22. Abdominal TraumaInvestigations: Labs • Most not too helpful acutely • Lipase/amylase can’t rule in/out pancreatic injury • Same with LFTs • What about in pediatric trauma?

  23. Case #1 - Radiology • FAST or CT abdo? (DPL not used here in Calgary)

  24. Table 1. Diagnostic parameters for ultrasound (U/S), computed tomography (CT) and diagnostic peritoneal lavage (DPL) in blunt abdominal trauma U/S, % CT, % DPL, % Sensitivity 91.7 97.2 100 Specificity 94.7 94.7 84.2 Accuracy 92.7 96.4 94.5 Abdominal TraumaComparison of Investigations • Comparison in CAEP

  25. Abdominal TraumaInvestigations: FAST • Free fluid after blunt trauma • perihepatic and hepatorenal space (Morrison’s pouch) • perisplenic • pelvis (Pouch of Douglas) • pericardium • Does not look at solid organs, retroperitoneum, diaphragm

  26. Abdominal Trauma • FAST exam of pelvis

  27. Abdominal TraumaFAST Algorithm

  28. Abdominal TraumaFAST Algorithm CAEP 1(2), 1999.

  29. Case #1 Continued • No blood on U/S but… • Pt stable since first fluid bolus • CT ordered • Oral contrast do you need it?? (Rosen’s- CT has low sensitivity for injury to small bowel, mesentary, pancreas) • Is it safe??

  30. CT +/- Oral Contrast • RCT, 500 pts @ level I trauma centre • Abnormal scans equal between groups • One unnecessary lap in each group • One missed SB injury with OC (sensitivity 86%), none missed in non OC group • No difference in sensitivity for solid organ injury (84% vs 88%) • Conclusion: oral contrast only slows CT for blunt abdo trauma Stafford, et al. Oral contrast solution and CT for blunt abdominal trauma. Arch Surg. 1999; 134 (6): 622-6.

  31. Safety of Oral Contrast • Retrospective review • 506 pts either drank contrast or had ETT and contrast via NG • No aspiration of contrast (except for pt with NG into R bronchus!) Federle, et al. Use of oral contrast material in abdominal trauma CT scans: Is it dangerous? Journal of Trauma. 1995; 38(1): 51-55.

  32. Oral Contrast and kids • Retrospective review of 101 children with blunt trauma • 60 pts received contrast • 37 (62%): duodenum not opacified after 30 min • Intestinal injuries found on laparotomy did not correlate to CT findings with/without oral contrast Shankar, et al. Oral contrast with CT in the evaluation of blunt abdominal trauma in children. BJSurg. 1999; 86(8); 1073-7.

  33. Abdo TraumaPediatrics • 85% blunt: MVA, pedestrian vs car, fall out of car, child abuse • Watch for coagulopathies • Poor musculature and less AP diameter increase risk of compression with blunt force • Difficulties include communication, fear, aerophagia (decompression may help ventilation and exam)

  34. Abdo Trauma in Kids • Prospective observational study • < 16yo (8.4+/-4.8 yrs), blunt trauma, at level I trauma center • 1095 pts, 107 (10%) with intra-abdo injury Holmes, JF. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002; 39(5): 500-9

  35. Case #2 • 22 yo male presents with stab wound to abdomen • BP 155/90, HR 90, mentating “well” • What historical features are important?

  36. Stab Wounds • Most stab wounds don’t cause intraperitoneal injury • Instrument (size, still in one piece) • # stabs • posture of patient

  37. Stab Wounds • 3 Q’s • Urgent laparotomy? • Peritoneum violation • If peritoneum violated: laparotomy? • Clinical indications (Rosen’s): hemodynamic instability, peritoneal signs, evisceration, diaphragmatic injury, GI bleed, implement-in-situ, intraperitoneal air

  38. Case #2 – do you want to explore the wound? • Shave and prep, local anesthetic • Extend wound and visualize layers • Do not blindly probe • Advocated for anterior abdo wounds, but all else ?? • Watch thoracolumbar junction Markovchick. Local wound exploration of anterior abdominal stab wounds. J of Emerg Med. 1985 2(4): 287-91.

  39. Penetrating Trauma • Anterior abdomen • Ant axillary line, costal margins, groin crease • Flank • Ant/post axillary line, inf scapula to iliac crest • Back • Post axillary line, inf scapula to iliac crest

  40. Case #2 continued • LWE – confident that knife did not penetrate the peritoneum • Is it reasonable to stitch him up and d/c from the ED?

  41. Selective Management • Retrospective review of 455 with penetrating truncal injuries (Detroit) • 194 directly to OR • 107 had selective w/u (triple contrast CT, LWE, observation) • 136 d/c home after hx, px, plain films • Missed 2 injuries w/o significant consequence • Conclusion: stable pts with negative selective w/u can be d/c’d home Conrad, et al. Selective management of penetrating truncal injuries. Am Surg. 2003; 69(3): 266-72.

  42. Case #2 • No free air on upright CXR, how sensitive is this? • 13 pts with abdominal trauma (blunt and penetrating) • Upright CXR sensitivity from 0% if less than 3 pockets of 1mm of air, to 100% if pocket of air > 13mm Stapakis. Diagnosis of pneumoperitoneum: abdominal CT vs upright chest film. J of Comp Assist Tomo. 1992; 16(5) 713-6.

  43. GSW

  44. Penetrating TraumaGSW • Ek = 1/2mv2 • E directly proportional to amount of injury • Other factors : resistance of tissue, stability of missle, impact velocity • Diagnostics and considerations similar to stabs

  45. Penetrating Trauma and CT • Prospective study, 104 pts with penetrating trauma (54 GSW, 50 Stab) • Triple contrast (oral/rectal/IV) helical CT • No indication for immediate lap • Positive CT = peritoneal violation, injury to retroperitoneal colon, major vessel, urinary tract • CT 100% sensitive, 96% specific, 100% NPV, 97% accuracy in predicting need for lap Shanmuganathan, et al. Triple-contrast helical CT in penetrating torso trauma. Am J Roen. 2001; 177:1247-56.

  46. Genitourinary Trauma • 10% of trauma has GU involvement (USA) • Lower Tract – Bladder and urethra • Upper Tract – renal and ureter • External genitalia

  47. Genitourinary Trauma

  48. Genitourinary Trauma

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