1. Abdominal Trauma Nestor Nestor, M.D., M.Sc. January 17, 2007

2. The Plan Abdominal Anatomy Abdominal Anatomy Mechanisms of Injury Mechanisms of Injury Common Pathology Common Pathology Evaluation Evaluation Management Management

3. Part 1: Abdominal Anatomy

4. Abdominal Anatomy Basics ABC’s ABC’s Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

5. Abdominal Anatomy Basics ABC’s ABC’s Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

6. Abdominal Anatomy Basics ABC’s ABC’s Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

7. Abdominal Anatomy Basics ABC’s ABC’s Many organs receiving substantial blood flow Many organs receiving substantial blood flow Potential spaces that can hide hemorrhage Potential spaces that can hide hemorrhage Hollow organ damage > Peritonitis Hollow organ damage > Peritonitis

8. Abdominal Anatomy: Four Quadrants

10. Abdominal Anatomy

14. Abdominal Anatomy: Four Quadrants

15. Alternative Divisions

16. Intraperitoneal Structures

17. Retroperitoneal Structures

18. Upper Abdomen CT

19. Lower Abdomen CT

20. Retroperitoneal

21. Part 2: Mechanisms and Pathology

22. Abdominal Injuries Blunt vs. Penetrating Blunt vs. Penetrating Often both occur simultaneously Often both occur simultaneously Blunt is the most common mechanism in US Blunt is the most common mechanism in US

23. Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

24. Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

25. Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

26. Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

27. Blunt Abdominal Trauma Direct impact or movement of organs Direct impact or movement of organs Compressive, stretching or shearing forces Compressive, stretching or shearing forces Solid Organs > Blood Loss Solid Organs > Blood Loss Hollow Organs > Blood Loss and Peritoneal Contamination Hollow Organs > Blood Loss and Peritoneal Contamination Retroperitoneal > Often asymptomatic initially Retroperitoneal > Often asymptomatic initially

28. Liver Lacerations I. Subcapsular Hematoma <10% Surface Area II. Subcapsular Hematoma 10-50% III. Subcapsular Hematoma >50% IV. Parenchymal Disruption of 25-75% V. Parenchymal Disruption of >75% VI. Liver Avulsion

30. Splenic Lacerations I. Subcapsular Hematoma <10% Surface Area II. Subcapsular Hematoma 10-50% III. Subcapsular Hematoma >50% IV. Laceration producing devascularization of >25% of the spleen V. Shattered Spleen

32. Evaluation: Be Suspicious Mechanism Mechanism Vitals Vitals Symptoms Symptoms Associated Injuries Associated Injuries Elderly or co-morbidities Elderly or co-morbidities Distracting injuries Distracting injuries Decreased MS/intoxication Decreased MS/intoxication

33. Techniques for Evaluation Physical Exam Serial exams in awake, alert and reliable pt Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvic are the standard Abd films little or no use, pelvic are the standardScreening Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams) Ultrasound: FAST (serial exams)

34. Techniques for Evaluation Physical Exam Serial exams in awake, alert and reliable pt Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvis are the standard Abd films little or no use, pelvis are the standardScreening Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams) Ultrasound: FAST (serial exams)

35. Techniques for Evaluation Physical Exam Serial exams in awake, alert and reliable pt Serial exams in awake, alert and reliable pt Plain Films Abd films little or no use, pelvis are the standard Abd films little or no use, pelvis are the standardScreening Diagnostic Peritoneal Lavage (DPL) Diagnostic Peritoneal Lavage (DPL) Ultrasound: FAST (serial exams) Ultrasound: FAST (serial exams)

36. FAST: RUQ

39. Techniques for Evaluation Organ Specific Dx Only CT Also evaluates retroperitoneum Expensive Radiation Ex Lap Laparotomy gold standard for evaluation Concomitant treatment Retroperitoneum difficult to explore/assess

40. Techniques for Evaluation Organ Specific Dx Only CT Also evaluates retroperitoneum Expensive Radiation Ex Lap Laparotomy is the gold standard for evaluation Concomitant treatment Retroperitoneum difficult to explore/assess

41. Penetrating Trauma Evaluation Mandatory exploration abandoned Mandatory exploration abandoned No digital exploration or contrast studies No digital exploration or contrast studies Inspect wound to determine if there is violation of the fascia Inspect wound to determine if there is violation of the fascia Difficult to assess stab wound trajectory Difficult to assess stab wound trajectory Determine if gunshot traversed the peritoneal cavity Determine if gunshot traversed the peritoneal cavity

42. Management ABC’s ABC’s Fluid resuscitate Fluid resuscitate To lap or not to lap? To lap or not to lap? Unstable (with no other reason) Unstable (with no other reason) Free air/peritonitis (antibiotics) Free air/peritonitis (antibiotics) Unexplained free fluid Unexplained free fluid Many splenic/liver lacs managed non- operatively or by VIR Many splenic/liver lacs managed non- operatively or by VIR

43. Penetrating Flank and Buttock Injuries Potential for peritoneal and/or retroperitoneal injury Potential for peritoneal and/or retroperitoneal injury Similar evaluation and management to abdominal Similar evaluation and management to abdominal Buttock injuries may also reach peritoneal and/or retroperitonal structures Buttock injuries may also reach peritoneal and/or retroperitonal structures

44. Genitourinary Trauma

45. GU Trauma 2-5% of adult traumas 2-5% of adult traumas Vast majority blunt mechanisms Vast majority blunt mechanisms 80% renal injuries 80% renal injuries 10% bladder injuries 10% bladder injuries Abnormalities (tumor, hydro) increase susceptibility Abnormalities (tumor, hydro) increase susceptibility Rarely require immediate intervention Rarely require immediate intervention

46. Evaluation Rectal - high riding prostate Rectal - high riding prostate Perineum - ecchymosis, lacs Perineum - ecchymosis, lacs Genitals - meatal/vaginal blood Genitals - meatal/vaginal blood Difficult catheter placement (may need suprapubic) Difficult catheter placement (may need suprapubic) UA – hematuria (poor correlation to degree of injury) UA – hematuria (poor correlation to degree of injury)

47. Evaluation U/S and Plain films of little use U/S and Plain films of little use CT is the superior imaging modality CT is the superior imaging modality Careful with contrast (nephropathy) Careful with contrast (nephropathy) Angiography remains the gold standard Angiography remains the gold standard IVP/Cystoscopy less useful in the ED IVP/Cystoscopy less useful in the ED

48. GU Injuries: The Kidneys Kidneys are well protected Kidneys are well protected Most commonly bruised Most commonly bruised Pts with a shattered kidney become rapidly unstable Pts with a shattered kidney become rapidly unstable Renal vascular injuries may result in thrombosed vessels Renal vascular injuries may result in thrombosed vessels

49. GU Injuries: The Kidneys Operative management for: uncontrolled hemorrhage uncontrolled hemorrhage Penetrating injuries Penetrating injuries Multiple lacs Multiple lacs Shattered kidney Shattered kidney Avulsed vessels Avulsed vessels

50. GU Injuries: The Bladder Contusion Contusion Rupture: Intra vs. Extraperitoneal Rupture: Intra vs. Extraperitoneal Extraperitoneal presents with pain, hematuria and inability to void Extraperitoneal presents with pain, hematuria and inability to void Urethral injuries: Anterior vs. posterior Urethral injuries: Anterior vs. posterior No Foley for urethral injuries No Foley for urethral injuries

51. Retroperitoneal Structures

52. In Summary... Basic knowledge of anatomy necessary for initial assessment of abdominal trauma Basic knowledge of anatomy necessary for initial assessment of abdominal trauma Peritoneal vs. Retroperitoneal Peritoneal vs. Retroperitoneal Blunt vs. Penetrating Blunt vs. Penetrating Don’t miss GU injuries Don’t miss GU injuries

53. Thank You