Blunt Abdominal Trauma Jen Nicol PGY-2 Dr. Rob Lafreniere August 5 th, 2010

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

Physical Exam in BAT Objectives

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

SNSP Overall92-98%99% Bowel / Mesentery 88%99% Diaphragm54-73%86-90% pancreas80%

Established need for laparotomy Prior abdominal surgery Infection Obesity Coagulopathy 2/3 rd 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 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 laparotomy Yes IPH? +ve FAST / DPL IP injury? Source of bleeding? CT scan, FAST, DPLObserve 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

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 Hematuria Visible 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

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)