b lunt a bdominal t rauma dr. sean wilde, pgy-3 (ccfp-em) aug 18 2011 preceptor: dr. trevor langhan

Blunt

Abdominal

TraumaDr. Sean Wilde,PGY-3 (CCFP-EM)Aug 18 2011Preceptor:Dr. Trevor Langhan

Game Plan• Stepwise approach to

BAT– The baseball diamond

approach– Adults only

• Intra-abdominal & GU trauma

• Classification by stability and patient evaluability

• Role of FAST• When can you avoid a CT

13% of all injuries areAbdominal Trauma

Case mortality is8%

Most deaths are in bluntabdominal trauma

Meet the Players…

Motor Vehicle Collisions

50-75% of BAT

Direct blows tothe abdomen

15%

(assaults and recreational activities)

Falls froma height

6-9%

Mechanisms

• Abrupt Intra-abdominal pressure changes

• Compression of abdominal contents

• Acceleration-deceleration forces

At Risk

• Spleen• Liver• Small bowel• Retroperitoneum• Kidneys• Bladder• Colorectal• Diaphragm• Pancreas

CHALLANGES

•Altered LOC

•Unreliable Physical Exam

•Multiple diagnostictests

•Significant miss ofintestinal andpancreatic injuries

Often multi-trauma

Develop the BAT reflex

Have a simple, step-wise approach to the management of the blunt abdominal trauma victim…

STABLE, EVALUABLEPATIENT

ARRESTING?

UNSTABLEPATIENT

STABLE: NORMALPHYS EXAM,-ve URINE,-ve FAST

BAT

SEND HOME

TO THEO.R.

Y N

? peritonitis? +ve FAST? Hematuria

? Unclear exam? –ve FAST

Fluid,

trans

fusio

n

~Consider othersources of bloodloss (pelvis, retroP)~ConsiderDPA/DPL

? Sta

ble

Is stable patient

reliably evaluable?

NO

CT ABDO/PELVIS

YES

? peritonitis

CT ABDO/PELVIS

? Physicalexam finding? +ve FAST? Gross hematuria? Micro hematuriaw rapid decel injury? Other CTable injury

Considerretrogradeurethrogram/cystogram

NO

YES

CONSULT

CT result

abno

rmal

Consider:~mech of injury

~associated injury~clinical gestalt

normal

ObservationSerial exams

Beware:hollow viscous,

diaphragm,pacreatic inj.

(CT poor)

ABC’s in BAT

• ABC / OIL

• Prioritize the injuries– Airway > Chest > Abdomen > Head > GU

• Don’t forget the Abdomen in multi-trauma!

• Feel the Belly!– More than once

• FAST scan is part of primary survey– Do it BEFORE the log roll.

The Baseball Diamond Approach to BAT

1. Stability• Arresting, unstable or stable?

2. OR Red flags• In the unstable vs stable patient• Initial resuscitation

3. To CT or not to CT• Is the patient evaluable?• What findings mandate/avoid a CT?• When is DPL useful?

4. Reassuring findings• going for home

Case 1

• 40yo male, MVC• Restrained driver• Passenger fatality• Unconscious at scene• Cardiac arrest pulling into

ambulance bay after 2 litres NS

• Diffuse chest and abdominal bruising with distended abdomen

• No major open injuries• CPR in progress,

asystole on monitor

I would:

A) Crack the chest for open cardiac massage

B) ATLS/ACLS and 2 fridges of blood

C) ED Laparotomy

D) Do nothing (“He’s dead Jim”)

E)

Plan:

Mortality after BAT arrest is dismal; worse than penetrating or chest trauma

Doing nothing is a valid option*

However, if you do go there….

1) Treat emergencies of the chest

2) Open Cardiac resuscitation

3) If you get a pulse:1) Cross-clamp aorta

2) Straight to OR

Fluid Resuscitation

• Colloids

– NS, Ringer’s

• Blood Early

• Massive Transfusion Protocols

6:6:1

ARRESTING?

BAT

TO THEO.R.

Y N

Fluid,

tran

sfusio

n

? Sta

ble

UNSTABLEPATIENT

Ongoing hemodynamic instability after initial fluid?

Stop at 1st base!

Stable vitals?

Head towards 2nd.

Case 2• 29y F, thrown from bike in

motocross accident• GCS 11-14, fluctuating• Non-ambulatory at scene• Full spinal precautions• HR 135, BP 70/55, O2

95% on 2L NP• Cries in pain when

transferred to bed• Hurts “everywhere!”

• Now what?

Trauma Survey– Chest unremarkable– Diffuse mild tenderness to abdomen– Pelvis stable but painful– FAST –ve– Long bones look OK– Lots of pain to RLQ/right hip on log roll

• Resuscitation– Brief improvement in vitals/GCS with fluid, then rapid

decline• Getting more drowsy• Hg 105 on ABG

Unstable BAT patientFluid/Blood Resuscitation

? Peritonitis? Positive FAST

? HematuriaTo the OR

Consider other sources ofblood loss and shock

? retroperitoneal hematoma

Consider DPA/DPL

YESTo any

NO•Exam unclear•FAST negative•Urine bland•Too unstable for imaging

Positive

InterventionalRadiology

Pelvic #

Negative

Toounstablefor CT!

Case cont…

• FAST is negative

• No peritonitis

• Microscopic hematuria after catheter

• Non displaced pelvic fracture on x-ray

• But the belly seems more tender than earlier…

FAST Facts

• Poor sensitivity– 200cc fluid for positive scan– Cannot use a negative scan alone to rule out

need for surgery

• Good specificity– For free abdominal fluid– Blood vs Urine

DPL?

1. Unstable, multi-injured patient with questionable abdominal source

2. Replace serial abdominal exam in head injured patient

3. Post normal CT with ongoing high suspicion of the abdomen

4. Remote area where CT unavailable- i.e. O.R. before transport?

ARRESTING?

UNSTABLEPATIENT

BAT

TO THEO.R.

Y N



Fluid,

tran

sfusio

n


? Sta

ble


BAT

Fluid,

trans

fusio

n

? Sta

ble

Is stable patient

reliably evaluable?

YESNO

CT ABDO/PELVIS

Rounding 1st base

• Hemodynamically stable BAT patient

• ASK: Can I reliably evaluate this patient?– GCS– Head injury– Intoxication– Distracting injury– Drugs

• NO = go to CT

• YES = arrive at 2nd base!

Case 3

• 45y M kicked in the stomach 7 hours ago

• Ongoing discomfort• Vitals normal and stable• Generalized abdo pain on

palpation– No peritonitis– No guarding– No visible bruising

• Urine clean• Next?

FAST

To CT Scan- Lacerated Spleen

CAT Scan in BAT

Very good sensitivity and specificity

Normal CT scan can be considered very reassuring

Critical management decisions

Oral Contrast?• Does not increase detection of HVI• Impractical/Risky (NG feeds on spine board)• Local trauma surgeons rarely use it

• Negative CT- Consider missed:– GI (hollow viscous) injuries– Diaphragmatic injuries– Pancreatic injuries

• Serial exams and CT Scans as indicated will catch most.

* Physical exam* FAST

* Check Urine* Consider mechanism

Surgery (+/- CT)

Any +ve Physical Exam FindingOR

Positive FASTOR

Gross hematuriaOR

Deceleration injury withMicroscopic hematuria

ORAny other injury requiring CT

Normal physical examNegative FASTNormal urine

Low risk Mech of injury

Observation vs DischargeConsider retrograde urethrogram

Stable BAT patient with reliable exam

DiffusePeritonitis

AbdoCT

Scan

Abdominal seatbelt sign:

IA injury rate 23% with, 3% without

Vertebral (Chance) #, mesenteric tears

BAT Physical Exam +ves

• Abdominal Seatbelt sign

• Pain with guarding

• Any peritoneal findings

• Remember value of repeat exams!!!



CT ABDO/PELVIS



NO

YES • Rounding 2nd base to 3rd

• Avoiding a CT so far…

• What’s between you and home plate?

Case 3 the remix…

• As before, kicked in stomach, ongoing pain.

• Vitals stable• This time all

investigations negative, including FAST

• What now?


SEND HOMECONSULT




• Consider mechanism, clinical gestalt

• Not worried?– D/C with FU

• Worried?– Can still CT

– Or Observation: serial abdominal exams, FAST, blood work

– Second opinion

3rd Base to Home Plate

Holmes, 2009. Low risk Clin Pred Rules in BAT

If none of:• GCS <14• Abdominal/costal margin tenderness• Hematuria• Hematocrit < 30%• Femur fracture• CHXR trauma findings

Negative predictive value of 99% for intra-abdominal injury

Serial abdominal exams (at least 2)

Negative FAST

Clean Urine

The Bare Minimum…

Case 4

• 29y M fell 12ft off “scissor lift.”

• Landed on his bottom• Stable, alert, c/o sore

buttocks• Head/spines cleared• Abdomen non-tender• FAST negative• Urine dips 3+ blood

GU Trauma• Blood at meatus• High riding/boggy

prostate• Unable to void• Hematuria (esp

gross)

Retrograde Urethrogram in suspected GU trauma

(Pre-catheter)

Post cath:Follow-up CT and Cystogram

(Upper GU Trauma)


ARRESTING?

UNSTABLEPATIENT


BAT

SEND HOME

TO THEO.R.

Y N



Fluid,

trans

fusio

n


? Sta

ble

Is stable patient

reliably evaluable?

NO

CT ABDO/PELVIS

YES

? peritonitis

CT ABDO/PELVIS



NO

YES

CONSULT

CT result

abno

rmal



normal


Beware:hollow viscous,

diaphragm,pacreatic inj.

(CT poor)

b lunt a bdominal t rauma dr. sean wilde, pgy-3 (ccfp-em) aug 18 2011 preceptor: dr. trevor langhan

Documents

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negativetoounstablefor