1
Q
Types of abd injuries
A
Blunt vs. penetrating
- Integument
- MSK
- Splenic
- Hepatic
- Vascular
- GI tract
- GU/renal
- Pancreatic
2
Q
Shock
- MC in trauma
A
hypovolemic/hemorrhagic
3
Q
Shock
- hypovolemic / hemorrhagic pathophys
A
- Sympathetic and adrenal response: increase PVR and HR
- Vasoconstriction of skin, muscle, kidney, splanchnic = blood to heart and brain
- Pulse pressure narrows as lose more volume, leads to hypotension as compensatory mechanisms are overwhelmed
- Cells turn to anaerobic metabolism = lactic acid = acidosis
4
Q
Hypovolemic or hemorrhagic shock
- Classification
A
- Class 1: <15% blood volume (750 mL)
- Class 2: 15-30% (800-1500 mL)
- Class 3: 30-40% (2000 mL)
- Class 4: >40%
5
Q
Hypovolemic or hemorrhagic shock
- S/sx
A
- Tachycardia
- Blood pressure normal to hypotensive
- Pulse pressure: normal to narrowed
- Cap refill: normal to delayed
- Skin: cool, pale, cold, ashen
- Tachypnea
- May see decreased urine output
6
Q
Hypovolemic or hemorrhagic shock
- Tx
A
- Stop hemorrhage
- Fluids
• Crystalloid if mild-moderate
• Blood transfusion if continued signs of hypoperfusion (fresh whole blood best): Type and cross match, if not avail use O-
• Vasopressors last resort
7
Q
Tranexamic Acid (TXA)
A
- Stops bleeding
- Loading dose 1 g IV 100cc NS over 10 min
- Infusion: 1 G IV 250cc NS over 8 hours
8
Q
FAST exam
A
Focused abdominal sonogram for trauma
- Looks for free fluid in the pericardial, pleural, and intraperitoneal spaces
- Visualize the heart, diaphragm, liver, spleen, and bladder: Morison’s pouch is located between R kidney and liver
9
Q
Splenic Injury
- types
A
- Subcapsular hematoma
- laceration
- fracture
- avulsion
- Arterial extravasation (aka contrast blush or arterial bleeding)
10
Q
Spleen fn
A
- Filtrate: particulate antigens, diseased cells, encapsulated organisms
- Immunologic: B lymphocyte reservoir, remove bacteria and ab, initiates immune reponse, produces ab (IgM)
Pitting: removal of nuclear remnants
11
Q
Classification of splenic, hepatic, and renal trauma
A
1-5
1 is least bad
5 is worst
12
Q
Splenic injury
- s/sx
A
- Hx consistent with splenic injury
- Nonspecific LUQ pain
- PE: LUQ tenderness and referred left shoulder pain (Kehrs sign)
- Mod decrease in bp, tachycardia, reduced H/H, increased WBC
13
Q
Splenic Injury
- Dx
A
- US: FAST to look for free fluid and peri-capsular hematoma
- CT of abd and pelvis with contrast (CI if unstable with acute trauma)
14
Q
Splenic injury
- Non-operative Tx
A
- Low grade injuries: minimal or no abd findings, hemodynamically stable, min lab evidence of blood loss, low E trauma, isolated injury on CT scan, no hilar involvement or massive disruption on CT
- ICU for 1-2 days, floor 2-5 days
- Serial H/H q 4 hr, decrease if stable
- Bedrest 48-72 hrs if H/H stable, then gradually increase while monitoring H/H
- If hemoglobin continues to drop after transfusion, consider sx
15
Q
Splenic injury
- operative tx
A
- Splenorrhaphy: grade 1-2, usually only performed if already doing laparotomy for something else
- Partial splenectomy: grade 4, >30% of spleen must be preserved to maintain immunologic function
- Splenectomy: via open exploratory laparotomy/celiotomy
16
Q
Splenic Injury
- Post-op complications
A
• MC atelectasis
• Also: pneumonia, pleural effusion, subphrenic hematoma/abscess, etc.
• Sepsis:
- Lose spleen = can’t mount immune response
- Vaccinations: Strep pneumonia, H. flu, meningitis prior to hospital discharge, booster in 5 years
- Education pts about risk, need to seek medical care if get fevers
17
Q
Splenic injury and hepatic injury discharge/care instructions
A
- 8-12 weeks no physical activity that can cause blunt abd trauma
- Possible US at 8-12 weeks to eval healing process
- No pushing, pulling, lifting >5 lbs for 6-8 weeks
18
Q
Hepatic Injury
- Overview
A
- MC in penetrating vs. blunt trauma
- Blunt trauma = more complex/likely to cause death
- Most death early post-op period dt shock and transfusion related coagulopathies
- Small to large increase in LFTs
- Big worry is coagulopathy
19
Q
Hepatic Injury
- Dx
A
- CT scan of abd/pelvis with contrast
- Additional eval may be needed
- May need to do a diagnostic peritoneal lavage, if positive = surgery:
• Invasive
• Will be positive even if only a small amt of (maybe insignificant?) blood in peritoneal cavity
• Positive: 100,000 RBC, 500 WBC, bile, particulate matter, amylase>serum amylase, 10 mL gross blood aspirated
20
Q
Hepatic Injury
- Tx
A
- Non-operative: Same as splenic injury
- Operative
• Prevent hypothermia and coagulopathies
• Keep warm and hydrated, don’t let them become hypovolemic!
• Techniques: Topical agents, hepatorrhaphy, cautery, manual compression, packing and drains, embolization of bleeding artery, etc.
21
Q
Renal Trauma
- overview
A
- Blunt trauma accounts for 90%, penetrating 10%: Blunt associated with other intra-abd injuries 44% of the time
- Children prone to disruption of UPJ with rapid deceleration injuries secondary to hyperextension of spine
- Lacerations dt fractured ribs/transverse processes of lumbar spine
22
Q
Renal trauma
- location of R and L kidney
A
- Right kidney: posterior to liver, close to colon and duodenum
- Left kidney: inferior to spleen, posterolateral to pancreas
23
Q
Renal trauma
- Dx
A
- CT abd/pelvis with triple contrast (PO, IV, rectal)
- Arteriogram: if non-visualization of the kidney, can ID renal devascularization which indicates renal vascular injury
24
Q
Renal Trauma
- s/sx
A
- Flank/upper abd tenderness
- Flank contusion/ecchymosis
- Lower rib fx
- Upper abd mass/fullness
- Crepitance over lower rib cage or lumbar area
25
Renal Trauma
| - lab
hematuria
26
Renal Trauma
| - Tx
- Minor (grade 1-2) are 70%, do not require intervention
- Major (grade 3-4) are 10-15%, management depends on clinical status and other associated injuries
- Grade 5 are 10-15%, require immediate sx to control life threatening bleeding, often result in nephrectomy
- Large devascularized segements may result in partial or complete nephrectomy
- Absolute indication for further exploration: persistent bleeding, expanding/pulsatile hematoma, hemodynamically unstable, grade 5
- Relative indication for further exploration: urinary extravasation of contrast from the bladder, devitalized segment, arterial thrombus
27
Renal Trauma
| - Post-op care
- Watch for HTN and persistent hematuria
- Closed suction drains
- Monitor H/H and BUN/Cr
28
Urinary Bladder Trauma
| - overview
- >85% with bladder rupture have other serious injuries, mortality rate 22-60%
- 85% also have pelvic fractures
- Rarely cause hemodynamic instability alone
- Blunt causes 75% of bladder trauma
29
Urinary Bladder Trauma
| - Contusion
- Bladder wall hematoma or mucosal disruption without loss of wall continuity or extravasation
- Dx: based on mechanism, hematuria, neg dx eval for rupture
30
Urinary Bladder Trauma
| - Rupture types
- Extraperitoneal: complete disruption of bladder wall into extraperitoneal space, usu at lateral bladder or at base
- Intraperitoneal: Complete disruption of bladder wall, usually dome of bladder, extravasation of urine into peritoneal cavity
- Combined: both
31
Urinary Bladder Trauma
| - dx
- Hx and PE. 98% have gross hematuria, complain inability to urinate, suprapubic pain
- Abd exam: TTP, ecchymosis, edema, pelvic instability
- GU/perineum exam: ecchymosis, edema, hematoma, urethral meatus blood: vaginal exam to rule out concomitant vaginal or urethra injury, or retained tampon
- Rectum: may reveal bleeding or high riding prostate. MUST perform before foley cath placement
32
Urinary bladder trauma
| - Imaging
- Retrograde urethrogram (RUG)
• Perform if blood at urethral meatus or perineal ecchymosis, if catheter cannot be passed or high riding prostate
- CT cystogram
• MC used
• Eval of other intra-abd injuries as well as bladder injuries
33
Urinary bladder trauma
| - Tx
- catheter drainage
| - Exploration, cystostomy, debridement and primary repair
34
Urethral Injuries
- NO FOLEY if suspect urethral injury or there is blood in the meatus
- MC dt straddle injury
- Urologist consult
35
Scrotal Injuries
- Laceration = urology consult
| - US to r/o torsion or epididymitis and/or rupture of testicle
36
Abdominal vascular injuries
- Renal, hepatic, splenic, superior mesenteric artery, IVC, abdominal aorta, iliac vessels
- Need vascular or trauma surgeon
- Large amts blood products, platelets, fresh frozen plasma
- Aggressive resuscitation
37
Small Bowel Injuries
- Seat belt contusion: worry about SM injury
- Penetrating GSW cause 80%, stab wounds cause 20%
- Blunt trauma 5-15%
- All GSW to abdomen = celiotomy
- Ct/US not reliable to ID hollow viscous injury unless lots of free air or intraperitoneal fluid
38
Small bowel injuries
| - tx
- Minor: simple sutures
| - Major: resection and primary anastomosis
39
Colon Injuries
- Occur in 15-40% penetrating abd wounds
- Blunt trauma rare, from blowout injuries from seatbelts in MVC
- CT scan of abdomen and pelvis with rectal contrast can help (CT not helpful for hollow viscous injury)
- Free air on radiographic studies
- Tx: primary repair, resection, anastomosis, colostomy
40
Pancreatic Injury
- Occur in 3-10% abdominal injuries, 2/3 dt penetrating trauma
- US and CT may be helpful to ID
- Grading: 1 least bad, 5 worst
- ERCP: evaluate ductal system, is invasive
- MRCP: not as sensitive but not invasive
- Tx: control hemorrhage, debride de-vascularized pancreas, JP drainage, pancreatectomy, jejunostomy
- Octreotide: decrease output from pancreatic fistulas
- Whipple: if transection of pancreatic head
41
Gastric Injury
- Occur in 7-20% of penetrating abd trauma, blunt trauma rare
- Free air indicative of perforation
- 98% can be tx with debridement and primary repair
- May need wound vac until edema subsides (also small bowel)
ER 2
flashcards
Decks in class (10)
# Cards
