Internal Injuries

DR TRUSHA BRYS

VFPMS

SEMINAR 2019

INTERNAL ORGAN INJURYBasic principles

• Solid organs may lacerate and bleed

• Hollow organs may rupture and leak Stomach, intestines, bladder, ureters + gall bladder

• Bone fragments may penetrate & damage deeper tissues

• Vessels in mesentery may tear resulting in large volume haemorrhage and organ ischaemia

• Veins are more vulnerable to physical trauma than artery

• Higher pressures are required to compress arteries than veins

• Probably under-recognised / under-detected

• Can be fatal

• Overlying skin may appear uninjured

• Strangulation (neck trauma)

• Intra-thoracic injury

• Intra-abdominal trauma

A BRIEF OVERVIEW

STRANGULATION

DEFINITION: is the external compression of the neck that can cause

consequences that may be fatal as a result of compression of and injury

to the vital structures of the neck such as airways, blood vessels and

nerves.

Strangulation

In adults/adolescents – seen in context of sexual

assault and intimate partner violence

In children – probably under-recognised

Beware if history of LOC or memory gaps after

assault

Might need 24 close observation because neck

structures swell and airways can be suddenly

compromised!

Treat any symptoms and signs of neck trauma

VERY seriously

www.strangulationtraininginstitute.com

NB: Absence of neck skin injury

does NOT exclude damage to

underlying neck structures

RCPA FCFM Strangulation Guideline

• Presenting signs and symptoms vary depending on mechanism.

• There is inadequate experience or data to recommend an evidence-based

approach to imaging in strangulation or near-hanging victims.

• Imaging should be ordered based on clinical suspicion.

• Plain radiographs.

• Fiber optic laryngoscopy.

• CT - sensitive for bony, cartilaginous, and soft tissue injuries, subcutaneous

emphysema, oedema, and haemorrhage.

• MRI -deep soft tissue injury and oedema.

• CT Angiography - blunt vascular injury - sensitivity up to 100% (for clinically

significant injuries).

• Carotid Doppler ultrasound.

• Cardiac and vascular injuries

• Pulmonary trauma

• Pharyngeal and oesophageal trauma

• Chylothorax

INTRA-THORACIC INJURY

CHILD PROTECTION EVIDENCE - SYSTEMATIC REVIEW ON VISCERAL INJURIES. RCPCH November 2018

A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Holmes JF, Sokolove PE, Brant WE, Kuppermann N Ann Emerg Med. 2002;39(5):492

Predictors of thoracic injury in children sustaining blunt torso trauma include

• low systolic blood pressure,

• elevated respiratory rate,

• abnormal results on thoracic examination, abnormal chest auscultation findings,

• femur fracture,

• and a GCS score of less than 15

• CXR

• Chest CT***

• Chest MRI (“whole body” MRI infants?)

• FAST (US)

• Think ABDO trauma

Intra-thoracic trauma – basic tests

• FBE

• Clotting

• O2 Saturation

• Blood gas

• Troponin

Bilateral pleural effusions

Pericardial effusion

Infant also had

• Liver laceration

• Small amount of free fluid sub-

diaphragm

• Large distended gall bladder

INTRA-ABDOMINAL TRAUMAInjuries associated with NAT to anterior abdomen

Forces transmitted through anterior abdo wall – +/- external sign

• Haematoma anterior abdominal wall

• Splenic rupture and hhge

• Liver laceration and hhge

• Rupture 1st part of duodenum• Free air beneath diaphragm (erect and supine x-rays)

• Pancreatic compression, rupture, pancreatitis • Late – pancreatic pseudocyst

• Tear of bowel mesentery and hhge• Ileus (bowel)

• Rupture bladder, ureters

illustration of traumatic abdominal injuries

- liver laceration, duodenal injury

(?compression against the vertebral

column), and pancreatic injury

Injuries associated with NAT to posterior abdomen

Forces transmitted through posterior abdo wall – +/- external sign of injury (more rigid than anterior torso)

• Haematoma flank / torso

• Renal trauma, capsule rupture and hhge

• Vertebral body and spinous processes

• Spinal cord

• Sacrum and pelvis

• THINK - Compression – pancreatic, mesentery and bowel trauma

Intra-abdo trauma –reference++

• Every organ can be injured

• Intrathoracic injury in < 5 yo

• NAT = younger than accidental abdo trauma

• Duodenal injury NAT (3rd and 4th part)

• Liver and pancreas common in NAT

• Abdo bruising absent in ~80%

Visceral injury – systematic review

Intra-abdominal trauma

Liver laceration

with intra-

abdominal

haemorrhage

Attributed to NAI

Upper abdominal organs may be damaged by

• direct blow to the epigastrium with deformation of the abdominal wall,

• Eg punch or kick

• avulsion of the blood supply by rapid deceleration,

• Eg a fall from height , thrown

• puncture by a fractured rib,

• crushing against the vertebral column

Splenic trauma

Duodenal Haematoma

• Duodenal haematoma from blow to abdomen (Medscape)

• May cause bowel obstruction

Pseudocyst

Pancreatic Trauma

Epigastric abdo pain + raised enzymes

Pancreatitis in children 23% caused by trauma

(25% unknown cause)

URINALYSIS

• So easy to do

• So often forgotten!

Renal contusion and sub-capsular haemorrhage

• FAST

-ve result reassuring

• Abdo CT + contrast

• Abdo x-ray

• MRI (“whole body” infants)

• Lavage / laparoscopy

Intra-abdo trauma tests

• FBE (Serial Hb, retics)

• Clotting

• LFT (might repeat)

• U&E

• Lipase, amylase

• URINALYSIS

1.Identify injuries

2.Look for patterns

3.What are the circumstances ?

4.What investigations to assist with assessments ?

5. Should I be concerned about possible internal injuries?

VFPMS GUIDELINES - visceral injury including abdominal injury

Useful references and articles

◦ The Royal College of Paediatrics and Child Health’s review (UK, 2018) Child Protection Evidence on

Visceral Injury evaluates the literature on visceral injuries and provides data on the following questions:

What are the features of visceral injuries occurring as a consequence of physical abuse? What is the

value of non-radiological investigation in detecting abusive abdominal injury?

◦ Trout AT et al.’s article (2010) Abdominal and pelvic CT in cases of suspected abuse: can clinical and

laboratory findings guide its use? discusses pre-test probabilities of CT Scan in the context of suspected

physical abuse

◦ Maguire SA et al.’s article (2013) A systematic review of abusive visceral injuries in childhood – Their

range and recognition presents the data on visceral injuries in the context of physical abuse and calls for

clinical vigilance.

◦ Lane WG et al.’s article (2009) Screening for Occult Abdominal Trauma in Children with Suspected

Physical Abuse presents a strong argument in favour of screening for abdominal injury in abused

children

THANK YOU