Chapter 5.  Identify key anatomic features of the abdomen  Describe blunt and penetrating injury patterns  Describe the evaluation of the patient with.

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Presentation transcript:

Chapter 5

 Identify key anatomic features of the abdomen  Describe blunt and penetrating injury patterns  Describe the evaluation of the patient with suspected abdominal injury

 Identify and apply the most appropriate diagnostic and therapeutic procedures  Discuss acute management of pelvic fractures

 What priority is abdominal trauma in the management of the multiply injured patient?  Why is the mechanism of injury important?  How do I know if shock is the result of an intra-abdominal injury?

 How do I determine if there is an abdominal injury?  Who warrants a celiotomy (laparotomy)?  How do I manage patients with pelvic fractures?

Flank Do not forget the back!

Upper peritoneal cavity Lower peritoneal cavity Pelvic cavity Do not forget the retroperitoneal cavity.

 What is one of the leading causes of preventable mortality? Unrecognized intra- abdominal injury

 Head and abdominal trauma?  Head, chest and abdominal trauma?  Head, chest, abdominal and extremity trauma?  Head, chest, abdomen, extremity and pelvic trauma?

 Why is it important to know? It determines what organs are probably injured

 How does it injure? ◦ Compression ◦ Crushing ◦ Shearing ◦ Decelerations  What organs are commonly injured? ◦ Spleen ◦ Liver ◦ Small bowel

 How does it injure? ◦ Stab: low energy ◦ Lacerations ◦ Gunshot: high energy ◦ Transfer of kinetic energy  What organs are commonly injured? ◦ Low energy: liver, small bowel, diaphragm, colon ◦ High energy: small bowel, colon, liver, vascular

 Blunt: ◦ Speed ◦ Point of impact ◦ Intrusion ◦ Safety devices used ◦ Position ◦ ejection  Penetrating: ◦ Weapon ◦ Distance ◦ Number of wounds

 Inspection  Auscultation  Percussion  Palpation

 Stab wound: ◦ How do I evaluate and manage the abdomen of a patient with an anterior abdominal, lower chest, flank, or back stab wound?  Penetrating injuries ◦ How do I evaluate and manage perineal, rectal, vaginal or gluteal penetrating injuries?  Gunshot wound ◦ How do I evaluate and manage the abdominal GSW?

 Evidence of abdominal injury by mechanism, history or evaluation  Interventions: ◦ Gastric tube relieves distention, decompresses stomach before DPL ◦ Urinary catheter monitors urinary output, decompresses bladder before DPL ◦ Laboratory tests ◦ X-ray studies, contrast studies

DPLFAST*CT TimeRapid Delayed TransportNo Required SensitivityHighHigh?High SpecificityLowIntermediateHigh EligibilityAll patients Hemodynamically normal *Operator dependent

 Penetrating: ◦ Suspect if hypotensive, retroperitoneal injury, peritonitis ◦ Lower chest wounds, anterior abdominal stab wounds, back and flank stab wounds ◦ Exploration, CT, DPL, serial exams  Blunt trauma: ◦ Suspect if dropping BP, free air, diaphragmatic rupture, peritonitis ◦ Operative exploration, CT

 Mechanism ◦ AP compression ◦ Lateral compression ◦ Vertical shear ◦ Significant force ◦ Associated injuries ◦ Pelvic bleeding

 Assessment ◦ Inspection ◦ Palpate prostate ◦ Pelvic ring: leg length discrepancy, external rotation, pain on palpation of bony pelvic ring  Management ◦ Fluid resuscitation ◦ Determine if open or closed fracture ◦ Determine associated injuries ◦ Determine need for transfer ◦ Splint pelvic fracture

Determine if intra-peritoneal gross bloodYesLaparoscopy Control hemorrhage NoAngiography Fixation device

 ABCDEs and early surgical consultation  Evaluation and management vary with mechanism and physiologic response  Repeated exams and diagnostic studies  High index of suspicion  Early recognition/prompt laparoscopy