1. Evaluation of Abdominal Trauma Anand Pandya MD FRCSC Trauma Surgery and Critical Care Medicine Clinical Associate St. Michael’s Hospital, University of Toronto Principles of Surgery

2. Objectives Evaluation of Abdominal Trauma Evaluation of Abdominal Trauma Mechanisms of Injury Mechanisms of Injury Assessment of Unstable Patients Assessment of Unstable Patients Assessment of Stable Patients Assessment of Stable Patients Case Discussions Case Discussions Diagnostic tests Diagnostic tests Decision making Decision making

3. External Anatomy of Abdomen

4. Mechanism of Injury: Blunt Compression, crush, or sheer injury to abdominal viscera: deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus) Compression, crush, or sheer injury to abdominal viscera: deformation of solid or hollow organs, rupture (e.g. small bowel, gravid uterus) Deceleration injuries: differential movements of fixed and non- fixed structures (e.g. liver and spleen laceration at sites of supporting ligaments) Deceleration injuries: differential movements of fixed and non- fixed structures (e.g. liver and spleen laceration at sites of supporting ligaments)

5. Pattern of Injury in Blunt Abdominal Trauma Spleen40.6%Colorectal3.5% Liver18.9%Diaphragm3.1% Retroperitoneum9.3%Pancreas1.6% Small Bowel 7.2%Duodenum1.4% Kidneys6.3%Stomach1.3% Bladder5.7% Biliary Tract 1.1% * Rosen: Emergency Medicine (1998)

6. Mechanism of Injury: Penetrating ● Stab ● Low energy, lacerations ● Gunshot ● Kinetic energy transfer ● Cavitation, tumble ● Fragments

7. Assessment: History AMPLE AMPLE Mechanism Mechanism MVC: MVC: Speed Speed Type of collision (frontal, lateral, sideswipe, rear, rollover) Type of collision (frontal, lateral, sideswipe, rear, rollover) Vehicle intrusion into passenger compartment Vehicle intrusion into passenger compartment Types of restraints Types of restraints Deployment of air bag Deployment of air bag Patient's position in vehicle Patient's position in vehicle

8. Assessment: Physical Exam Inspection, auscultation, percussion, palpation Inspection, auscultation, percussion, palpation Inspection: abrasions, contusions, lacerations, deformity Inspection: abrasions, contusions, lacerations, deformity Grey-Turner, Kehr, Balance, Cullen Grey-Turner, Kehr, Balance, Cullen Auscultation: careful exam advised by ATLS. (Controversial utility in trauma setting.) Auscultation: careful exam advised by ATLS. (Controversial utility in trauma setting.) Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum Percussion: subtle signs of peritonitis; tympany in gastric dilatation or free air; dullness with hemoperitoneum Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding Palpation: elicit superficial, deep, or rebound tenderness; involuntary muscle guarding

9. A missed abdominal injury can cause a preventable death. Abdominal Injury Factors that Compromise the Exam ● Alcohol and other drugs ● Injury to brain, spinal cord ● Injury to ribs, spine, pelvis Caution

11. Case 1 40 yo male, MVC – driver 40 yo male, MVC – driver GCS=7, Airway GCS=7, Airway 100% on 15L face mask 100% on 15L face mask BP=80/50, P=140 BP=80/50, P=140 Diagnosis? Diagnosis? Management? Management?

12. Decision Making Airway Airway Breathing Breathing Circulation Circulation Hemodynamically Stable Hemodynamically Unstable Transient Responder S H O C K How are you going to assess?

13. Shock Scalp Scalp Chest – clinically vs. chest x-ray Chest – clinically vs. chest x-ray Abdomen Abdomen FAST FAST DPL DPL Pelvic X-ray Pelvic X-ray Extremities – Femur Extremities – Femur Other causes of shock – cardiogenic, obstructive, anaphylactic, septic Other causes of shock – cardiogenic, obstructive, anaphylactic, septic

14. FAST

15. Focused Abdominal Sonography for Trauma (FAST) Demonstrate presence of free intraperitoneal fluid Demonstrate presence of free intraperitoneal fluid Evaluate solid organ hematomas Evaluate solid organ hematomas Advantages Advantages No risk from contrast media or radiation No risk from contrast media or radiation Rapid results, portability, non-invasive, ability to repeat exams. Rapid results, portability, non-invasive, ability to repeat exams. Disadvantages Disadvantages Cannot assess hollow visceral perforation Cannot assess hollow visceral perforation Operator dependent Operator dependent Retroperitoneal structures are not visualized Retroperitoneal structures are not visualized

16. FAST Four View Technique: Four View Technique: Morrison’s pouch (hepatorenal) Morrison’s pouch (hepatorenal) Douglas pouch (retropelvic) Douglas pouch (retropelvic) Left upper quadrant (splenic view) Left upper quadrant (splenic view) Epigastric (View pericardium) Epigastric (View pericardium)

17. Diagnostic Peritoneal Lavage Introduced by Root (1965) Introduced by Root (1965) Indications for DPL in blunt trauma: Indications for DPL in blunt trauma: 1. Hypotension with evidence of abdominal injury 2. Multiple injuries and unexplained shock 3. Potential abdominal injury in patients who are unconscious, intoxicated, or paraplegic 4. Equivocal physical findings in patients who have sustained high-energy forces to the torso 5. Potential abdominal injury in patients who will undergo prolonged general anesthesia for another injury, making continued reevaluation of the abdomen impractical or impossible

18. Contraindications of DPL Absolute : Absolute : Peritonitis Peritonitis Injured diaphragm Injured diaphragm Extraluminal air by x-ray Extraluminal air by x-ray Significant intraabdominal injury by CT scan Significant intraabdominal injury by CT scan Intraperitoneal perforation of the bladder by cystography Intraperitoneal perforation of the bladder by cystography Relative : Relative : Previous abdominal operations (because of adhesions) Previous abdominal operations (because of adhesions) Morbid obesity Morbid obesity Gravid Uterus Gravid Uterus Advanced cirrhosis (because of portal hypertension and the risk of bleeding) Advanced cirrhosis (because of portal hypertension and the risk of bleeding) Preexisting coagulopathy Preexisting coagulopathy

19. DPL: Procedure

20. Evaluation of DPL Fluid is sent for: cell count, amylase, alk phos, presence of bile Fluid is sent for: cell count, amylase, alk phos, presence of bile Index Positive value AspirateBlood >10 mL Fluid Enteric content LavageRBC > 100,000/mL WBC > 500/mL Amylase >175 U/dL Alk Phos > 3 IU BileConfirmed NegativeRBC < 50,000/mL WBC < 100/mL Amylase < 75 U/dL

21. Diagnostic Peritoneal Lavage RBC Count Incidence of visceral damage >100,00095% 20,000-100,000 15-25% Warrant further investigation <20,000 < 5% Complications of DPL: Perforation of small bowel, mesentery, bladder and retroperitoneal vascular structures. Complications of DPL: Perforation of small bowel, mesentery, bladder and retroperitoneal vascular structures. Limitation: offers no information about status of retroperitoneal organs nor allow determination of which organ has been injured. Limitation: offers no information about status of retroperitoneal organs nor allow determination of which organ has been injured.

22. Indications for Laparotomy – Blunt Trauma ● Hemodynamically abnormal with suspected abdominal injury (DPL / FAST) ● Free air ● Diaphragmatic rupture ● Peritonitis ● Positive CT

23. On Route to OR ABC ABC Chest x-ray, Pelvis x-ray Chest x-ray, Pelvis x-ray IV access IV access Resuscitation Resuscitation What is the goal? What is the goal? Group and Match Group and Match Notify OR, Surgeon, Anaesthesia Notify OR, Surgeon, Anaesthesia Request OR equipment Request OR equipment Consent Consent Antibiotics Antibiotics

26. Case 1: Learning Points Recognize Shock Recognize Shock Hemodynamically unstable = OR Hemodynamically unstable = OR Role of FAST, DPL Role of FAST, DPL Permissive hypotension in resuscitation until bleeding controlled Permissive hypotension in resuscitation until bleeding controlled

27. Case 2: 40 yo male, MVC Driver 40 yo male, MVC Driver Airway Airway Breathing = 100% on 5L NP Breathing = 100% on 5L NP Circulation = 130/70, P=100 Circulation = 130/70, P=100 Disability, GCS=14 Disability, GCS=14 Exposure Exposure Management? Management?

28. How do you investigate the Abdomen? Hemodynamically stable: Hemodynamically stable: ABCDE, secondary survey ABCDE, secondary survey FAST FAST CT Scan CT Scan Lab work Lab work

29. Imaging in Blunt Abdominal Trauma – CT Scan Sensitivity: Sensitivity: Solid organ injury: 97% [II,III] Solid organ injury: 97% [II,III] Identify Contrast extravasation Identify Contrast extravasation Guide Operative vs. Non-operative management Guide Operative vs. Non-operative management Enteric injury: 64 – 94% [III] Enteric injury: 64 – 94% [III] Diaphragmatic injury: 61% [III] Diaphragmatic injury: 61% [III] Pancreatic injury: 30% [III] Pancreatic injury: 30% [III]

30. CT Scan

33. Role of Laboratory Tests Amylase Amylase B-HCG B-HCG

34. In Pregnancy X-rays X-rays Ultrasound Ultrasound Abdominal Abdominal Fetal Fetal Circumferential Lead Shield Circumferential Lead Shield Caution with Radiation exposure Caution with Radiation exposure

35. Decision Making Stable patient Stable patient CT Scan CT Scan Operative Operative Solid organ injury, hypotensive Solid organ injury, hypotensive Hollow viscus organ injury Hollow viscus organ injury Intraperitoneal bladder injury Intraperitoneal bladder injury Diaphragmatic injury Diaphragmatic injury Non-operative management Non-operative management Observation Observation Interventional Radiology Interventional Radiology

36. Learning Points Case #2 CT scan is helpful for decision making in a stable patient CT scan is helpful for decision making in a stable patient Poor detection of hollow viscus, pancreatic and diaphragmatic injury Poor detection of hollow viscus, pancreatic and diaphragmatic injury Be worried of free fluid in abdomen Be worried of free fluid in abdomen Repeat CT Scan and close clinical observation Repeat CT Scan and close clinical observation

37. Case #3 30 yo male 30 yo male GSW to buttock GSW to buttock Airway Airway Breathing Breathing Circulation Circulation What injuries are you concerned about? What injuries are you concerned about? How are you going to investigate? How are you going to investigate?

38. Transpelvic GSW Rectal injury Rectal injury Extraperitoneal – rigid sigmoidoscopy Extraperitoneal – rigid sigmoidoscopy Intraperitoneal – CT scan with rectal contrast or laparotomy Intraperitoneal – CT scan with rectal contrast or laparotomy Bladder injury Bladder injury Hematuria Hematuria Cystogram Cystogram Urethral injury Urethral injury Retrograde urethrogram Retrograde urethrogram

39. Transpelvic GSW Vascular injury Vascular injury FAST FAST CT Scan CT Scan Pelvic fracture Pelvic fracture X-ray X-ray Female – Uterine injuries Female – Uterine injuries CT Scan CT Scan

41. Decision Making Low threshold for laparotomy with GSW Low threshold for laparotomy with GSW Bowel injury = sigmoidoscopy Bowel injury = sigmoidoscopy Intraperitoneal – repair/resect Intraperitoneal – repair/resect Extraperitoneal – diversion Extraperitoneal – diversion Bladder injury = cystogram Bladder injury = cystogram Intraperitoneal – surgical repair Intraperitoneal – surgical repair Extraperitoneal – foley catheter Extraperitoneal – foley catheter

42. Learning Points Case #3 Think of associated injuries Think of associated injuries GSW have blast effect, variable trajectory GSW have blast effect, variable trajectory Diagnostic tests guide treatment Diagnostic tests guide treatment Early laparotomy Early laparotomy

43. Case #4 30 yo male 30 yo male Stab wounds to abdomen Stab wounds to abdomen Airway Airway Breathing Breathing Circulation Circulation What is your management? What is your management?

44. Options for Management LaparotomyHemodynamic Stability? Diffuse Abdominal Tenderness YesNo Indications for Laparotomy – Penetrating Trauma ● Hemodynamically abnormal ● Peritonitis ● Evisceration ● Positive DPL, FAST, or CT ● Violation of peritoneum

45. Options for Management Hemodynamically stable penetrating injury Hemodynamically stable penetrating injury Serial Observation Wound Exploration DPL CT scan +/- Contrast Laparoscopy Laparotomy Ultrasound/echo – cardiac box Pericardial window – cardiac box

46. Stab Wounds 330 patients over 12 months 154 (47%) acute abdomen, underwent immediate celiotomy Even of these, 31% negative 176 (53%) observed 3 (1.7%) injuries required celiotomy (no adverse effects) Shorr RM, Gottlieb MM, et al. Selective management of abdominal stab wounds: Importance of the physical examiantion. Arch Surg 1988, 123(9):1141-5.

47. The Value of Serial Observation

48. Learning Points Case #4 Injury from stab wounds are different from GSW Injury from stab wounds are different from GSW Indications for early surgery Indications for early surgery Consider diagnostic options Consider diagnostic options Value of serial exam Value of serial exam

49. Case #5 50 yo male, MVC driver 50 yo male, MVC driver Airway Airway Breathing Breathing Circulation Circulation 100/70, P=130 100/70, P=130 What is the next step? What is the next step?

50. Priorities ABC ABC Consider associated injuries with pelvic trauma Consider associated injuries with pelvic trauma Blood vessels – arterial and venous Blood vessels – arterial and venous Bone Bone Bladder and urethral Bladder and urethral Bowel Bowel Baby (Uterus) Baby (Uterus) Other Body injuries Other Body injuries

51. Vascular Anatomy 1.Abdominal Aorta 2.Common Iliac Artery 3.Internal Iliac 4.External Iliac 5.Superior Gluteal 6.Obturator Artery

52. AP Pelvic # with bladder injury

53. The Pelvic Mantra…. Unstable Fractures Lead to Unstable Patients - stability should be tested by GENTLE manipulation - stability should only be performed ONCE Minimize further hemmorage !

54. Young-Burgess Classification System LCAPC VS Unstable

55. Decision Making Hemodynamically Stable Hemodynamically Stable CT Scan + cystogram CT Scan + cystogram If blush then observe vs. embolize If blush then observe vs. embolize Hemodynamically unstable, Pelvis unstable Hemodynamically unstable, Pelvis unstable FAST or DPL to rule out intra-abdominal injury FAST or DPL to rule out intra-abdominal injury Bedsheet wrap pelvis, Ex-fix, C-clamp Bedsheet wrap pelvis, Ex-fix, C-clamp If intraperitoneal blood = laparotomy If intraperitoneal blood = laparotomy If no intraperitoneal blood = Angiogram If no intraperitoneal blood = Angiogram

56. Angiography and Embolization Right iliac angiogram: acute extravasation (left) from the right superior and inferior lateral sacral arteries. Post-embolization (right) showing no evidence of acute arterial bleeding Initial AngiogramPost-Embolization

57. Learning Points Case #5 Unstable vs. Stable patients Unstable vs. Stable patients Recognize pelvic fracture Recognize pelvic fracture Rule out bladder injuries Rule out bladder injuries Angiogram and emobolization of arterial injuries Angiogram and emobolization of arterial injuries

58. Role of Interventional Radiology Embolization Embolization Spleen Spleen Liver Liver Pelvis Pelvis Angioplasty + Stent Angioplasty + Stent Renal artery dissection Renal artery dissection Stent Stent Thoracic aortic injuries Thoracic aortic injuries

59. Spleen Embolization

60. Renal Artery Dissection

61. Blunt Thoracic Aortic Injury

62. Summary Mechanism of injury – Blunt vs. Penetrating Mechanism of injury – Blunt vs. Penetrating ABC  Stability of trauma patients ABC  Stability of trauma patients Select ppropriate diagnostic imaging Select ppropriate diagnostic imaging Think about associated injuries Think about associated injuries Multi-modality Multi-modality Clinical Clinical FAST FAST CT Scan CT Scan Interventional Radiology Interventional Radiology Surgical exploration Surgical exploration

63. Questions