Trauma– Blunt Abdominal Trauma Douglas M. Maurer, DO, MPH

Learning Objectives Recognize and respond appropriately to a patient with hemorrhagic shock Assess via bedside methods the source of hemorrhage Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition

Introduction Blunt abdominal trauma is common. Unknown history, distracting injuries, and altered mental status make these patients difficult to diagnose and manage. Victims frequently have both abdominal and extraabdominal injuries. Family physicians need to be able to recognize and treat hemorrhagic shock.

Recognition of Hemorrhagic Shock Shock: oxygen delivery < tissue demands Treatment must restore tissue perfusion not just blood pressure Shock does NOT SBP < 90mmHg Recognition includes: mechanism of injury, patient’s appearance, vitals, level of mentation, peripheral perfusion and urine output Clinical parameters should be coupled with objective markers of tissue perfusion--serum lactate, base deficit, etc.

Practical Diagnosis of Shock Perform a targeted physical examination Diagnostic testing should include chest radiography, pelvis radiography, and bedside ultrasound Objective serum makers of tissue perfusion (serum lactate or base deficit) Point of care H/H, send CBC, type/cross DON’T delay resuscitation for lab results

6 Steps to Treat Hemorrhagic Shock Step 1: Effectively manage the airway and optimize oxygenation. Step 2: Identify and control immediate threats to central perfusion. Step 3: Identify and address severe intracranial injuries. Step 4: Identify and control other potentially life-threatening thoracic and abdominal injuries. Step 5: Identify and control potentially limb-threatening injuries. Step 6: Identify and treat noncritical injuries.

Treatment of Hemorrhagic Shock Obtain immediate type and crossmatch for 6-8 units of blood Massive transfusion defined as > 10 U of PRBCs in 24 hrs Consider use of PRBC to platelet to FFP ratio of 1:1:1 May result in decreased need for blood products Give calcium to prevent citrate toxicity 

Assessing for Sources of Hemorrhage Chest radiography: Tension pneumothorax? Massive hemothorax? Aortic injury? Pelvis radiography: Pelvic ring disruption? Focused Assessment with Sonography for Trauma (FAST): Pneumo/hemothorax? Hemopericardium? Hemoperitoneum? If positive, then emergency laparotomy. If negative, continue resuscitation, treat other causes.

FAST Facts Reliably identifies 200-250ml of intraperitoneal fluid Cannot reliably evaluate retroperitoneum/hollow viscous injury Sensitivity/specificity: 75%/98%, NPV: 94%; 86-97% accurate Performed using a curvilinear 2.5 or 3.5 MHz probe increased sens/spec with serial exams set gain so fluid in heart is black

FAST Views Cardiac: parasternal or subxiphoid, hepatocardiac interface, pericardial space. RUQ: hepatorenal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney. LUQ: splenorenal interface, diaphragm, inferior pole of kidney, inferior tip of spleen. Suprapubic: outline of bladder, silhouette of uterus (females). 4 main views to obtain (stand at pt’s right) Cardiac (probe indicator to pt’s right): parasternal or subxiphoid, hepatocardiac interface, cardiac wall motion, pericardial space RUQ (probe indicator cephalad, mid-axillary line, 11/12th ribs): hepatorenal interface (Morrison’s Pouch), diaphragm, inferior pole of kidney LUQ (probe indicator cephalad, mid-axillary line, 10/11th ribs): splenorenal interface, diaphragm, inferior pole of kidney, inferior tip of spleen Suprapubic (probe indicator to pt’s right, just cephalad to pubic bone): outline of bladder, silhouette of uterus (females)

FAST Algorithm Unstable patient: + FAST = OR. Stable pt: + FAST = abdominal CT. Stable pt, low mechanism of injury: - FAST = observation, serial exams. CT is the “Gold Standard”. CT far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. CT is the Gold Standard

What About Diagnostic Peritoneal Aspiration (DPA)? Can be performed if - FAST in blunt abdominal trauma. If DPA +, then emergency laparotomy. If DPA -, then seek and treat other sources. Perform serial abdominal exams. Perform serial FAST exams. If patient stabilizes, then CT. Get surgery involved!

Indications for Emergency Laparotomy Peritonism Free air under the diaphragm Significant gastrointestinal hemorrhage Hypotension with + FAST scan or + DPA  Do NOT keep trauma patients if you lack resources to care for them! **Persistent or recurrent hypotension in the patient with hemoperitoneum is an indication for immediate laparotomy. If patient is hemodynamically stable, then options include: Serial physical examinations +/- FAST scans and observation. CT abdomen with IV contrast (DPL is an alternative if CT abdomen is not available)  The choice depends on various factors: availability of imaging; availability of experienced staff to perform serial examinations; patient preference following informed consent; presence of other indications for definitive imaging e.g. seat belt sign, suspected retroperitoneal injury, etc. CT abdomen is primarily used in a hemodynamically stable to identify intraperitoneal injuries in the absence of significant hemorrhage. FAST scan can detect 250 mL of intraperitoneal free fluid, depending on the operator. As such it is useful for identifying significant intraperitoneal hemorrhage. However, ultrasound is not reliable for identifying specific organ injuries or minor hemorrhage.   ** An important point is that if the above discussed radiographic modalities and/or general surgeon experienced in the care of trauma are not available in your institution, then the patient must be transferred. Do not keep sick trauma patients if you do not have the resources to care for them.  An important take home is that if these aren’t available in your institution (including a surgeon who can do something about it), then the patient needs to be transferred. Don’t keep sick trauma patients if you don’t have resources to take care of them

Summary Recognize and treat hemorrhagic shock aggressively with blood products Assess for hemorrhage with bedside methods: CXR, pelvis, and FAST Unstable patient: + FAST = OR. Stable pt: + FAST = abdominal CT. Stable pt, low mechanism of injury: - FAST = observation, serial exams.

References Puskarich MA. Initial evaluation and management of blunt abdominal trauma in adults. In: UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012. Nickson C. “Trauma! Blunt abdominal trauma decision making.” Weblog entry. Life in the Fastlane Blog. http://lifeinthefastlane.com/2012/03/trauma-tribulation-023/ Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma. 2010 Edition. Chicago, IL. http://www.east.org/resources/treatment-guidelines/category/trauma American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.

Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma Douglas M. Maurer, DO, MPH, FAAFP

Simulation Training Assessment Tool (STAT)– Blunt Abdominal Trauma Date: 1 May 2013 Instructor(s): Clark, Maurer, Cuda Learner(s): SCENARIO ALGORITHM SET UP: “Rural” ER Simulated Room Bedside US and/or FAST simulator Real patient with simulated skin/abdomen PRE ARRIVAL: FP in rural ER, lab, rad, OR 35 y/o male s/p unrestrained driver MVA arrives via EMS, in c-collar. VS BP 90/50, HR 110, RR 18, SpO2 97% on RA, GCS 15 ARRIVAL: Full spinal precautions, has 1 IV in place. Pt awake, alert, conversing, but in mild distress, no meds, no allergies, no sig PMHx or PSHx PRIMARY SURVEY: A – talking initially, then somnolent B – labored, RR 24, nl breath sounds C – BP 85/40, HR 130, cool extremities D – GCS 14, somnolent, oriented to person when responds to voice E – no other trauma, mild abd distension, hypoactive BS SECONDARY SURVEY: Other exam normal, c-spine non tender, pelvis stable, rectal guaiac negative Abdominal exam tense, tender, absent BS LABS & IMAGES: Chest, c-spine, pelvis negative Labs – WBC 9, H/H 8/24, platelets 150, lactate 4, VBG: 7.35/46/40/50%/-8 Positive FAST in RUQ, no CT indicated Blood type and screen/X-match DISPOSITION: Must transfuse blood , call Surgeon and direct to OR, otherwise pt dies of hemorrhage Learning Objectives: 1. Recognize and respond appropriately to a patient with hemorrhagic shock. 2. Assess via bedside methods the source of hemorrhage. 3. Respond appropriately to evidence of intra-abdominal hemorrhage with regards to initial management and disposition. CRITICAL ACTIONS ME NI M SUSTAIN IMPROVE Completes Primary Survey: recognizes shock MK2 Safety net – IV, oxygen, monitors (2 x 16G IV) Completes Secondary Survey: recognizes abdominal source Completes bedside FAST (+ Morrison’s Pouch) PC5 Recognizes positive FAST: calls surgery Bedside labs: POC CBC, lactate, BAL, VBG, blood type/screen/X-match Bedside rads: port chest, lat C-spine, AP pelvis Gives emergency release blood transfusion If unstable: no CT, to OR If stabilizes: CT, then OR TOTAL SBP4 ME = Meets Expectations; NI = Needs Improvement, M = Milestones (see debriefing sheet)

Perihepatic This photo outlines the normal anatomy one should see on the perihepatic view Note the: liver, kidney and diaphragm Blood/free fluid would be b/t the liver capsule and renal fascia If really good may be able to note liver/renal lacerations, diaphragmatic herniations

Perihepatic This photo shows an abnormal fluid/blood collection b/t the liver and kidney

Perisplenic This photo shows the NORMAL anatomy seen on the perisplenic view Note the: spleen, kidney, rib shadows—something you will frequently see when you scan both upper quadrants

Perisplenic ABNORMAL perisplenic scan c free fluid collection b/t spleen and kidney as well as in pericolic gutter

Pelvic Pelvic scan with normal anatomy Note the bladder, and rectus abdominus muscle

Pelvic Abnormal pelvic scan showing blood/fluid collection below the bladder

Pericardium Photo showing normal anatomy during a pericardial scan Note the: rib shadowing, liver, diaphragm, ventricles—cannot see any abnormal fluid in the potential space of the pericardium

Pericardium Abnormal pericardial scan showing large pericardial fluid collection in trauma pt c cardiac tamponade