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

2. 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

3. 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.

4. 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.

5. 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. 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.

7. 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 

8. 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.

9. 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

10. 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)

11. 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

12. 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!

13. 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

14. 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.

15. 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.
Eastern Association for the Surgery of Trauma Guidelines Workgroup. Evaluation of blunt abdominal trauma Edition. Chicago, IL.
American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.

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

17. 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)

19. 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

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

21. 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

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

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

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

25. 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

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