abdominal pelvic trauma and its emergency managment.pptx

trauma to abdomen and pelvic

1. Abdominal and Pelvic Trauma By Birhanu D 10/6/2024 Trauma For ECCN 1

2. Objectives Identify the key anatomic regions of the abdomen. Recognize a patient at risk for abdominal and pelvic injuries based on the mechanism of injury. Apply the appropriate diagnostic procedures to identify ongoing hemorrhage and injuries that can cause delayed morbidity and mortality. Identify patients who require surgical consultation and possible laparotomy. Describe the acute management of abdominal and pelvic injuries. 10/6/2024 Trauma For ECCN 2

3. Scenario A 35-year-old male passenger was in a high-speed motor vehicle collision. His vital signs are: blood pressure 105/80 mm Hg; heart rate 110; and respiratory rate: 18. Glasgow Coma Scale (GCS) score is 15. The patient is complaining of pain in the chest, abdomen, and pelvis. 10/6/2024 Trauma For ECCN 3

4. Introduction Evaluation of the abdomen and pelvis is a challenging . Assessing abdominal and pelvic hemorrhage in any pt with blunt injury is necessary Penetrating torso wounds between the nipple and perineum also must be considered as potential causes of intraperitoneal injury. Mechanism of injury Injury forces Location of injury Hemodynamic status Unrecognized abdominal and pelvic injuries continue to be a cause of preventable death. Delay in recognizing intraabdominal or pelvic injury can lead to early death from hemorrhage or delayed death from visceral injury. 10/6/2024 Trauma For ECCN 4

5. Anatomy of the Abdomen 10/6/2024 Trauma For ECCN 5

6. Mechanisms of Injury Blunt Trauma Compression from crush between solid objects such as the steering wheel/seat belt & the vertebrae Shearing causing a tear or rupture from stretching @ points of attachment Penetrating Trauma Stab Wounds Gunshot Wounds Blast Impalement - Missiles 10/6/2024 Trauma For ECCN 6

7. A direct blow , can cause compression and crushing injuries to abdominal viscera and pelvis. Such forces deform solid and hollow organs Can cause secondary hemorrhage , contamination by visceral contents, and associated peritonitis. Most frequently injured organs Spleen (40% to 55%), Liver (35% to 45%), Small bowel (5% to 10%). Retroperitoneal hematoma (15%) BLUNT TRAUMA 10/6/2024 Trauma For ECCN 7

8. PENETRATING TRAUMA Stab wounds and low-velocity gunshot wounds cause tissue damage by lacerating and cutting. Stab wounds traverse adjacent abdominal structures and most commonly involve the Liver (40 %) Small bowel (30 %) Diaphragm (20 %) Colon (15 %) 10/6/2024 Trauma For ECCN 8

9. Gunshot wounds may cause additional intraabdominal injuries based upon the trajectory, cavitation High-velocity gunshot wounds transfer more kinetic energy to abdominal viscera. Due to temporary cavitation and bullet fragmentation, surrounding tissue will be damaged. It involves Small bowel (50%) Colon (40 %) Liver (30 %) Abdominal vascular structures (25 %) 10/6/2024 Trauma For ECCN 9

10. Pitfall Failure to understand the mechanism leads to lowered index of suspicion and missed injuries , such as: Underestimation of energy delivered to abdomen in blunt trauma Visceral and vascular injuries caused by small external low-velocity wounds, especially stab and fragment wounds. Underestimation of the amount of energy delivered in high-velocity wounds, leading to missed injuries tangential to the path of the missile Scenario n continued The patient has left-sided lower chest tenderness with abrasions of his left chest, left abdomen, and left flank. He is tender in the left upper quadrant and has pain with pelvic rock. His pelvis is stable. 10/6/2024 Trauma For ECCN 10

11. Assessment How do I know if shock is the result of an intraabdominal or pelvic injury? In hypotensive patients, the goal is to rapidly determine if an abdominal or pelvic injury is present and whether it is the cause of hypotension. History P/E: Inspection Auscultation Percussion Palpation Grey turner sign 10/6/2024 Trauma For ECCN 11

12. Assessment of Pelvic Stability Major pelvic hemorrhage occurs rapidly, and the diagnosis must be made quickly so that appropriate resuscitative treatment can be initiated . This procedure should be performed only once during the physical examination It should not be performed in patients with shock and an obvious pelvic fracture. 10/6/2024 Trauma For ECCN 12

13. Urethral, Perineal , and Rectal Examination Blood at the urethral meatus strongly suggests a urethral injury . Inspect the scrotum and perineum for ecchymosis or hematoma, also suggestive of urethral injury. For sustained blunt trauma , goals of the rectal examination are to assess sphincter tone and rectal mucosal integrity 10/6/2024 Trauma For ECCN 13

14. Relieves distention Decompresses stomach before DPL Gastric Tube Urinary Catheter Monitors urinary output Decompresses bladder before DPL Diagnostic Adjuncts Blood and Urine Tests No mandatory blood tests before urgent laparotomy Hemodynamically abnormal: type and crossmatch , coagulation studies Pregnancy testing Alcohol or other drug testing Hematuria (gross versus microscopic) 10/6/2024 Trauma For ECCN 14

15. Adjuncts…. 10/6/2024 Trauma For ECCN 15

16. Diagnostic Studies Blunt Trauma 10/6/2024 Trauma For ECCN

17. Diagnostic Studies Penetrating Trauma – Hemodynamically Normal Lower chest wounds Serial exams , FAST , thoracoscopy , laparoscopy, or CT scan Anterior abdominal stab wounds Wound exploration, DPL, FAST or serial exams Back and flank stab wounds DPL, serial exams, or double- or triple-contrast CT scan 10/6/2024 Trauma For ECCN 17

18. FAST Focused assessment with sonography for trauma (FAST) To diagnose free intraperitoneal blood after blunt trauma 4 areas: Perihepatic & hepato -renal space (Morrison ’ s pouch) Perisplenic Pelvis (Pouch of Douglas/ rectovesical pouch) Pericardium ( subxiphoid ) sensitivity 60 to 95% for detecting 100 mL - 500 mL of fluid Trauma.org Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 18

19. FAST Morrison ’ s pouch ( hepato -renal space) trauma.org Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 19

20. FAST Perisplenic view trauma.org Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 20

21. FAST Retrovesicle (Pouch of Douglas) Pericardium (subxiphoid) trauma.org Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 21

22. FAST Advantages: Portable, fast (<5 min), No radiation or contrast Less expensive Disadvantages Not as good for solid parenchymal damage, retroperitoneum , or diaphragmatic defects. Limited by obesity, substantial bowel gas, and subcut air. Can’ t distinguish blood from ascites. High (31%) false-negative rate in detecting hemoperitoneum in the presence of pelvic fracture Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 22

23. Diagnostic Peritoneal Lavage (DPL) Largely replaced by FAST and CT In stab wounds, for immediate dx of hemoperitoneum , determination of intraperitoneal organ injury, and detection of isolated diaphragm injury In GSW, not used much Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 23

24. Diagnostic Peritoneal Lavage Attempt to aspirate free peritoneal blood >10 mL positive for intraperitoneal injury Insert lavage catheter by seldinger , semiopen , or open Lavage peritoneal cavity with saline Positive test: In blunt trauma, or stab wound to anterior , flank , or back : RBC count > 100,000/mm 3 In lower chest stab wounds or GSW: RBC count > 5,000-10,000/mm 3 Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 24

25. Local Wound Exploration To determine the depth of penetration in stab wounds If peritoneum is violated, must do more diagnostics Prep, extend wound, carefully examine (No blind probing ) Indicated for anterior abdominal stab wounds, less clear for other areas Rosen ’ s Emergency Medicine, 7 th ed. 2009 10/6/2024 Trauma For ECCN 25

26. Laparotomy Who requires a laparotomy? 10/6/2024 Trauma For ECCN

27. Laparotomy Indications for Laparotomy – Blunt Trauma Hemodynamically abnormal with suspected abdominal injury (DPL / FAST) Free air Diaphragmatic rupture Peritonitis Positive CT Hemodynamically abnormal Peritonitis Evisceration Positive DPL, FAST, or CT Indications for Laparotomy – Penetrating Trauma Early operation is usually the best strategy for GSW 10/6/2024 Trauma For ECCN 27

28. Management of Blunt abdominal injury (BAT) 10/6/2024 Trauma For ECCN 28

29. Cont … 10/6/2024 Trauma For ECCN 29

30. Management of penetrating abdominal injury (PAT) 10/6/2024 Trauma For ECCN 30

31. 10/6/2024 Trauma For ECCN 31

32. Pelvic Fractures Significant force Associated injuries Pelvic bleeding Venous / arterial 10/6/2024 Trauma For ECCN 32

33. Pelvic Fractures Inspection Leg-length discrepancy, external rotation Open or closed Palpation of pelvic ring, stability Rectal / GU / vaginal exam Open or closed? Palpate prostate Assessment of Pelvic Fractures 10/6/2024 Trauma For ECCN 33

34. Pelvic Fractures AB, as usual C: Control hemorrhage Wrap / Binder Rule out abdominal hemorrhage Angiography, fixation, open surgery How do I manage patients with pelvic fractures? 10/6/2024 Trauma For ECCN 34

35. Pelvic Fractures Hemodynamically Abnormal Patients Surgical consult Pelvic wrap Intraperitoneal gross blood? Yes No Laparotomy Angiography Control hemorrhage Fixation device 10/6/2024 Trauma For ECCN 35

36. Management Fix major pelvic disruption and control hemorrhage Fluid resuscitation. Hemorrhage control is achieved through mechanical stabilization of the pelvic ring and external counter pressure . A sheet, pelvic binder, or other device can apply sufficient stability for the unstable pelvis at the level of the greater trochanters of the femur 10/6/2024 Trauma For ECCN 36

37. 10/6/2024 Trauma For ECCN 37

38. These temporary methods are suitable to gain early pelvic stabilization. The binders are only a temporary procedure , and caution is necessary, as tight binders can cause skin breakdown and ulceration over the bony prominences. As a result, patients with pelvic binders need to be carefully monitored . 10/6/2024 Trauma For ECCN 38

39. Angiographic embolization ongoing hemorrhage (best option) Since significant resources are required to care for patients with severe pelvic fractures, early consideration of transfer to a trauma center is essential. 10/6/2024 Trauma For ECCN 39

40. Thank You!! 10/6/2024 Trauma For ECCN 40