Blunt Abdominal Trauma

Jen Nicol PGY-2Dr. Rob LafreniereAugust 5th, 2010

Objectives

• Physical Exam in BAT• 3 important diagnostic modalities• Management goals in BAT• Hematuria in BAT• Common pitfalls

• Physical Exam in BAT

Objectives

http://2.bp.blogspot.com/_aBun-fJmULo/SBjL0jllTkI/AAAAAAAAAok/nkr4FgX3Go8/s1600-h/drunk.jpg

Accuracy of physical exam in BAT is 55-65%

• In the alert patient–Pain– Tenderness with

guarding–Peritoneal findings

• High index of suspicion

Unreliable Findings• Equivocal exam• +/- normal physical

exam

Buckle up!

• Mesentery injury• Bowel perforation,

contusion• Rib & spine fractures• Diaphragm injury (rare)

Big Badness!

What is wrong with this picture?

Chance Fracture

Most common L1-3

50% con-current abdominal injuries

Objectives

• 3 important diagnostic modalities

If we all had these.....

It would be easy

Pain

Hematuria

Decreasing hematocrit levels

Negative FAST

FAST outcomes

CAT Scan

SN SP

Overall 92-98% 99%

Bowel / Mesentery

88% 99%

Diaphragm 54-73% 86-90%

pancreas 80%

Established need for laparotomy

Prior abdominal surgeryInfection

ObesityCoagulopathy

2/3rd trimester pregnancy

Sensitivity 87-95%Specificity 97-99%Accuracy 92-98%

Positive DPL In BAT:>10 mL aspirated blood

>100,000 RBC on lavage

Lavage output thorugh foley or chest tube

20,000-100,000 RBC indeterminite in BAT

DPL falsely negative in 25% of diaphragm injury

Objectives

• Management goals in BAT

Management Goals:

Stabilize the patient

Determine presence of intraperitoneal hemorrhage

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

Hemodynamically Unstable?

Laparotomy

Yes

Clinical Indication for laparotomyYes

IPH?

+ve FAST / D

PL

IP injury?Source of bleeding?

CT scan, FAST, DPL Observe

No

BAT

Hemodynamically Unstable?

Clinical Indication for laparotomy

IPH?IP injury?

Reliable exam

No

Abdominal tenderness

Other serious injuries

No

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

DPA / PDL negative

No intra-abdominal hemorrhage, no hemothorax

Massive bleeding, exanguinating hematoma posterior torso.

Transfused copious amounts blood products

To interventional radiology

Arrests, dies on table

35 yo roofer falls of a 12 ft roof at work.

2min LOC, confused and disoriented, GCS 13 (E3V4M6).

Case 2

90 palp; HR 86; SaO2 100%2L; RR 18; temp 36.9

abdomen firm, mildly tender LUQ

http://photobucket.com/

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

Insert XR here

More awake, less pain post femoral nerve block

Mild generalised abdominal pain

++++ RBC on urine cath dip

What to do now??

Objectives

• Hematuria in BAT

WHEN THE WHITE TURNS RED....

Microscpopic Hematuria dipstick positive

>5 RBC / HPF

Gross HematuriaVisible blood of any degree

Gross Hematuria

Microspcopic hematuria and shock (SBP<90)

Significant deceleration injury

Suspected intra-abdominal injuries

(J urol 1995;154:352)

Little Adults?

CT abdo / pelvis: •No acute injury•Kineys normal

Admitted to ortho fracture managment

22 year old M

Ran over by combine wheel near High River

STARS to FMC

Case 4

HR 123; BP 99/50; RR 20; SaO2 99 5L; temp 37

Grossly deformed pelvis

FAST negative x2 operators

3L NS 2U PRC’s - BP 90/48

Pelvic Fracture

Hemodynamically Stable?

FAST / DPL Positive?

Laparotomy

No

Angiography&

Pelvic fixation

Observation

Yes

No

IPH?

FAST, CT, DPL

Yes

FAST in pelvic fractures

SN 81% SP 87%

What does a negative FAST mean?

Rt internal iliac artery embolized with coil

Persistently tachycardic, hypotense

Taken to OR

17 yo M, aspiring Ducati racer

Flipped numerous times with bike before coming to stop

Wearing helmet, no leathers

Case 5

HR 119; BP 135/80; RR16; SaO2 99% 2L

Abdomen is +++tender – road rash over abdomen, torso, extremities

FAST negative

FAST negative

We decide to scan his abdo/pelvis

•Free fluid on 3 slices•no identifiable intra-abdominal organ damage

Free Fluid

Undetected solid organ injury

Bowel injury

Mesentery injury

Case 6

32 yo F assaulted with baseball bat by boyfriend

Intoxicated, Rt eye swollen shut

HR110; BP100/50; RR26; SaO2 96%RA, temp 37.4

Very tender LUQ – “he got a few good shots there”

CT scan normal, no free fluid, nil acute

Reassess frequently, more sober, still tender.

Observed until end of shift, tenderness dissipated, vital signs stable.

Negative CT scan

Discharge

Admit for observation

(J trauma 1998;44:273)

(Academic Emerg Med 2010;15:89

Discharged to Woman’s centre

Decides to press charges against her

boyfriend

• Common pitfalls

Objectives

False Negative Prediction

(Emerg Med Clin N Am 2010;28:1)

False attribution

(Emerg Med Clin N Am 2010;28:1)

Failure to assess the abdomen and plevis

(Emerg Med Clin N Am 2010;28:1)

Missed injuries

(Emerg Med Clin N Am 2010;28:1)