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Abdominal TraumaEpidemiologyHigh risk: lower rib # (# 8-10th ribs has 20% assoc risk of splenic inj), major inj to chest/pelvis, high speed MVA, ped vs car, fall >standing height, class II/III shock, inj on bilateral sides of abdoPaeds: bladder/liver/spleen less protected, less abdo wall fat, mobile omentum for deceleration inj1 in 10 trauma deaths due to abdominal trauma (10%)AssessmentMissed intra-abdo inj major cause of preventable death in trauma patients; should occur during C of ABCHistory: AMPLE historyExamination: Localised tenderness 85-90% sens, 45% spec; unreliable if altered LOC / spinal inj / retroperitoneal inj; significant trauma often occurs in absence of external signs; lap belt mark (Chance #, SI inj, pancreatic inj); PR (frank blood, high riding prostate, # palpation), PV, blood; unexplained hypotension, change in BP with time and IVF; local exploration of penetrating wound (deep fascia breeched? Peritoneum breeched?)InvestigationIndications for imaging: abdo tenderness, macroscopic haematuria, unexplained hypoV assoc with altered LOC / lower rib # / multiple distracting injuriesFAST: aim to identify FF and pericardial effusion Sens and spec: 96% sens for >800ml FF, 90% sens for >250ml FF; 95% spec 100% sens, 96% spec, 100% NPV for determining need for laparotomy in hypotensive pt insufficient sens to rule out significant inj in stable patient Areas viewed: hepato-renal interface (Morrison’s pouch), spleno-renal interface, L+R CP angle, Pouch of Douglas, pericardium Pros: bedside test, quick, cheap, repeatable, sensitive in experienced hands; can detect 250ml FF; can look at ascending aorta, good quantification of intraperitoneal blood loss and damage to liver/speen, may get some info on retroperitoneal structures; suitable for screening mass casualties; non-invasive Cons: obese, unfasted, bowel gas, subC emphysema make hard; operator dependent, not available in smaller centres, low sens for less severe inj; FF non-specific; poor view of retroperitoneum, hollow viscus, diaphragm; requires trainingCT: Pros: excludes intra-abdo haem requiring OT; grades inj to determine need for OT; can be done with other CT; lower complication rate than DPL; less false +ives; good view of solid organs, retroperitoneum, bones, chest, pelvis; non-invasive; provides anatomical info; gives indication of renal perfusion and function Cons: not suitable for unstable patients; false –ives for hollow organs; done in CT; access to pt; upper limb inj may make hard to get through scanner; contrast scan; cost; low sens for intestinal / pancreatic / bladder / diaphragm injDPL: pass IDC and NGT infraumbilical incision, visualise peritoneum, incise peritoneum insert catheter angling towards sacrum aspirate fluids (if blood, +ive, up to 5ml clear fluid OK) instil 1L N saline (10ml/kg in children) tilt head and agitate abdo, leave for 5mins drain fluid remove at least 600-800ml, then take sample for cell counts. +ive = >20ml (>10ml in children) frank blood on free aspiration >100,000 RBC/ml if blunt >5000 RBC/ml if penetrating >500 WBC/ml (if <3hrs since inj) bile / food particles exit of lavage fluid out of other catheters ? = pink fluid of free aspiration 50,000-100,000 RBC/ml blunt 100-500 WBC/ml -ive = clear aspirate <100 WBC/ml Pros: 98% sens for haemoperitoneum; better than CT for SI inj; bedside; quick; cheap; minimal training; good in mass casualties (can do on multiple patients); good in unstable patients Cons: CI in pregnancy, multiple abdo scars, local contamination; invasive; high sens, low spec (30% non-therapeutic laparotomy rate); misses retroperitoneal injs; requires NG and IDC; provides no anatomical info; 15% false +ive with pelvic inj; false –ive if contained haematoma; 1% complication rate; may introduce intraperitoneal air; makes subsequent CT scanning difficult to interpret; rarely used therefore out of practiceCXR: free subdiaphragmatic gas, abdo viscera in chest, elevated hemidiaphragm, pleural effusionAXR: low sens and spec; detects FB’s, free air, ileus; for splenic inj: LUQ ST mass, displacement of splenic flexure / stomach / L hemidiaphragm, obliteration of psoas shadow, fluid between adjacent loops of bowelOthers: cystogram; NG contrast and XR for duodenal inj; ureteric contrast; angiography for pelvicMngLaparotomy in blunt trauma takes precedence over inj’s above diaphragm; if penetrating, only remove knife in OTIndications for laparotomy in abdo trauma: blunt trauma with CV instability; haemodynamic instability despite appropriate resus; penetrating trauma breeching peritoneum (2/3 breech); peritonism; evisceration; free gas of CXR; ruptured diaphragm; GSW; unstable patient with +ive FAST/DPLIndications for emergent laparotomy: +ive FAST / DPLSplenic trauma40-55%1st bluntEpidemiology: most common organ inj from blunt trauma (in 40-55% cases; including in children); stronger in kids; delayed rupture can occur after 2-14/7 (liquefaction of haematoma); high risk if lateral impact; RF for rupture: EBV, plasmodium vivax, splenomegalyAssessment: guarding/tenderness may not be severe; L shoulder tip pain, scapular pain; assoc with 8-10th rib #’sIx: CT: gold standard (>95% sens, 100% spec); false +ive – congenital splenic cleft, low CO non-homogenous perfusion, lack of delay after contrast admin USS: haematoma = hypoechogenic mass; perisplenic haematoma; FFTrt: OT needed for grade III and above; IVF; 20% require blood transfusion; usually mng non-operatively; angiography effective in 80% Indications for laparotomy: grade III/IV; grade I/II but other intra-ab inj suspected/confirmed, unstable, compound inj, failure of conservative trtLiver trauma40%1st penetrating2nd bluntEpidemiology: most common organ inj from penetrating trauma; also from deceleration inj; often assoc with splenic inj; present in 40% blunt abdo trauma patients (40-55% for splenic)Assessment: guarding/tenderness may not be severe; R shoulder tip pain; lower R rib fracturesIx: CT gold standard in stable patient; LFT low spec if population has high incidence of abnormal LFT’s; in children, AST >400 / ALT >250 = 90% sens for hepatic injTrt: OT needed for grade III and above; conservative (indicated in only 20% when blunt inj) if contained haematoma, unilobular fracture, no devascularised segments, small amount FF Damage control laparotomy: if severe; perihepatic packing to temporarily control bleeding stabilise in ICU OT 24-48hrs later; best if performed <10iu blood transfused; complications = abdo compartment syndrome Bowel trauma5%Epidemiology: blunt compression inj (present in 5% of such)Mesenteric inj: mesenteric haematoma / vascular lac; CT 85-95% sens, 75% spec for need for OT; haematoma treated conservatively, beware ileusSI inj: in 3% abdo inj; in 90% Chance # L spine (perf in 55%); tear in jejunum / ileum; often assoc with mesenteric inj; peritonism in 85% (may take hours to develop); initial CXR 25% sens; serial CXR 60% sens; CT shows free gas (40%), FF, extravasation of PO contrast (5%); DPL shows incr WBC/RBC ratio compared to plasma (>95% sens and spec); trt with NG and 1Y repairColonic inj: mortality 10%; OT for grade II or above; stoma if faecal contamination / shock / major destructive injDuodenal inj: penetrating inj, seatbelt inj; blunt inj more severe; fixated at duodenojejunal flexure and ampulla, shearing tear submucosal haematoma; severe if involvement >75% wall, 1st 2 parts of duodenum or CBD; incr amylase in 50%; erect AXR shows retroperitoneal gas (psoas and renal outline visible), intraperitoneal gas, gas in biliary tree, scoliosis to R, obliteration of R psoas shadow, distension of stomach; do contrast studies; OT if free perf; conservative if intramural haematoma without perf; 10% mortality from perforating inj, 15% from blunt; 10% duodenal fistula ratePancreatic traumaEpidemiology: penetrating inj; if blunt, assoc with duodenal inj / severe multi-organ inj; more common in children, with lap belts, with Chance #Ix: CT sens 50%, spec >90%; amylase – large no false +ives, 35% sens in bluntTrt: blunt – manage as pancreatitis; penetrating – ERCP and OTAdrenal haemorrhage2-5% incidence with blunt trauma; 95% unilateral, 80% R sided (as L adrenal vein doesn’t drain directly into IVC); assoc with chest inj in 65%; usually conservative trt, embolisation if ongoing haemUrogenital traumaRenal: most common urological organ injured (ie. 92% are contusions) (occurs in 2-5% blunt trauma, 10% of paeds); 70-80% are blunt; diagnosis often delayed Clinically significant = macroscopic haematuria, CV instability, loin tenderness; if microscopic haematuria repeat in 1-2/52 (if penetrating, investigate immediately) Ix with contrast CT (USS sens 30%; IVP has lower sens and spec than CT; MRI differentiates perirenal from intrarenal, age of bleed better than CT therefore use if equivocal findings) Grade I and II - conservative trt; 30% risk of delayed bleed if grade III trted conservatively; grade II/III, 15/75% require OT (grade III, OT if CV unstable, ongoing transfusion requirement, or needed for other inj; OT for grade IV and V); grade III/IV/V, 5/10/85% r require nephrectomyBladder: in 10-15% pelvic inj; 2nd most common GU inj; 85% assoc with pelvic #; usually blunt (defect will be larger than in penetrating); usually of dome; macroscopic haematuria present in >95%; either dome inj with intraperitoneal leak (occurs from blunt force with full bladder), or body inj with intrapelvic (extraperitoneal) leak (assoc with pelvic #), or contusion (partial thickness without rupture) Ix with cystography (at least 300ml contrast into bladder; if intraperitoneal, extravasates to pericolic gutters, around liver; if extraperitoneal, found in pelvis; 80% sens, 99% spec for intraperitoneal rupture); CT cystography if other inj suspected Transurethral catheter better than suprapubic; OT if dome, conservative if body (catheterisation and expectant mng)Urethra: more common than bladder inj, more common in males; usually blunt; usually below urogenital diaphragm 50% have no physical signs <1hr; may track over abdo wall, but not thigh; high riding prostate in 2%; if not perineal trauma, nearly all assoc with pelvic # (esp displaced sup pubic ramus, SI jt, bilateral sup and inf pubic ramus); usually PVB if female Ix with urethrogram (if high riding prostate / boggy haematoma on PR, then urethrogram is unneccessary as there is definitely post rupture) If minor, manage conservatively (scope guided catheterisation); if major, suprapubic catheter and OTUreter: penetrating; rare; initial haematuria in only 75%; Ix with CT or retrograde ureterogram; 50% distal 1/3, 50% prox 2/3; 25% grade II, >50% grade III; requires OTScrotum: intratesticular bleeding pressure necrosis; may cause intra-testicular haematoma (40-50% risk of infection / testicular necrosis), tunica albuginea rupture and haematocoele contained by tunica vaginalis suggesting testicular rupture USS may underestimate severity, may miss small tear in tunica albuginea Conservative trt if no testicular haematoma (RIcE); indications for OT (immediate exploration - orchidectomy rate 5%, short hospital stay, decr disability) = testicular haematoma, haematocoele, rupture of tunica albuginea, penetrating traumaNotes from: Dunn, computer notes, Cameron Italics = requires OTOrganIIIIIIIVVV!SpleenSubcapsular haematoma <10% SA Capsular lac <1cm depthSubcapsular haematoma 10-50% SA Lac 1-3cm depth not involving trabecular BV Single/multiple lacs not involving hilumSubcapsular haematoma >50% SA or expanding Lac >3cm depth or involving trabecular BVRuptured subcapsular / intraparenchymal haematoma Intraparenchymal haematoma >5cm or expandingLac involving segmental / hilar vessels with <25% devascularisation of spleenHilar vascular inj with devascularisation of spleen Shattered spleenLiverSubcapsular haematoma <10% SA, non-expanding Capsular lac <1cm depth involving only parenchyma, not bleedingSubcapsular haematoma 10-50% SA, non-expanding Intraparenchymal haematoma <2cmLac 1-3cm depth or active bleeding; <10cm length Subcapsular haematoma >50% SA or expanding Lac >3cm depth or active bleeding25% mortalityRuptured subcapsular haematoma with active bleeding / Expanding central haematomaLobular tissue destricution >50% hepatic lobe30% mortalityInjuries to major hepatic vessels without avulsion Lobular tissue destruction >50% of hepatic lobe lesions of both hepatic lobes66% mortalityHepatic avulsion100% mortalityColonContusion / haematoma without devascularisationPartial thickness lac without perfLac <50% circumferenceLac >50% circumferenceTransectionTransection with tissue loss Devascularisation of segmentPancreasMinor contusion / superficial lac without duct inj Major contusion / lac without duct inj / tissue lossDistal injury with duct involvementProx inj (ie. To R of SMV)Massive disruption of pancreatic headRenalHaematuria with normal urologic studies Small, subcapsular, non-expanding haematomaLac <1cm deep without urine extravasation Haematoma confined to retroperitoneumLac >1cm deep without urine extravasationDeep lac into collecting system renovascular inj with contained haematomaRenal fracture avulsion of hilum with devascularised kidneyBladderPartial thickness lac Contusion / intramural haematomaExtraperitoneal bladder wall lac <2cmExtraperitoneal bladder wall lac >2cmIntraperitoneal bladder wall lac <2cmIntraperitoneal bladder wall lac >2cmIntra/extra peritoneal bladder wall lac extensing into neck / ureteral orificeUrethraContusionBlood at meatus but normal imagingElongation of urethra without extravasationPartial disruption with extravasation, but contrast in bladderComplete disruption (<2cm separation) with extravasation, but no contrast in bladderComplete disruption (>2cm separation)Extension into prostate / vaginaUreterContusion / haematoma without devascularisation<50% transection>50% transectionComplete transection with devascularisationAvulsion of hilum with devascularisation ................
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