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

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

4. Physical Exam in BAT Objectives

6. Accuracy of physical exam in BAT is 55-65%

7. In the alert patient – Pain – Tenderness with guarding – Peritoneal findings High index of suspicion

8. Unreliable Findings Equivocal exam +/- normal physical exam

9. Buckle up!

10. Mesentery injury Bowel perforation, contusion Rib & spine fractures Diaphragm injury (rare) Big Badness!

12. What is wrong with this picture?

13. Chance Fracture

14. Most common L1-3 50% con-current abdominal injuries

15. Objectives 3 important diagnostic modalities

16. If we all had these..... It would be easy

22. Pain Hematuria Decreasing hematocrit levels Negative FAST

24. FAST outcomes

25. CAT Scan

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

30. Established need for laparotomy Prior abdominal surgery Infection Obesity Coagulopathy 2/3 rd trimester pregnancy

31. Sensitivity 87-95% Specificity 97-99% Accuracy 92-98%

32. Positive DPL In BAT: >10 mL aspirated blood >100,000 RBC on lavage Lavage output thorugh foley or chest tube 20,000-100,000 RBC indeterminite in BAT

33. DPL falsely negative in 25% of diaphragm injury

34. Objectives Management goals in BAT

35. Management Goals: Stabilize the patient Determine presence of intraperitoneal hemorrhage Demonstrate organ injury requiring operative intervention Don’t miss injuries!

36. Clinical Indications for laparotomy in BAT Unstable VS, strongly suggestive abdominal injures Unequivocal peritoneal irritation Evidence of diaphragmatic injury Significant GI bleeding

37. BAT Hemodynamically Unstable? Laparotomy Yes Clinical Indication for laparotomy Yes IPH? +ve FAST / DPL IP injury? Source of bleeding? CT scan, FAST, DPLObserve No

38. BAT Hemodynamically Unstable? Clinical Indication for laparotomy IPH? IP injury? Reliable exam No Abdominal tenderness Other serious injuries No

39. Case 1 50 yo M rolled his dump truck while intoxicated Prolonged extrication – 2 hrs+ Intubated for low GCS, STARS to FMC

40. 78/48; 125; SaO2 96% 100%FiO2; temp 36.4; FAST indeterminite VBG pH 7.26, hbg90, lactate 3.5 ↑ PTT/INR, low plts

41. DPA / PDL negative

42. No intra-abdominal hemorrhage, no hemothorax Massive bleeding, exanguinating hematoma posterior torso.

43. Transfused copious amounts blood products To interventional radiology Arrests, dies on table

44. 35 yo roofer falls of a 12 ft roof at work. 2min LOC, confused and disoriented, GCS 13 (E3V4M6). Case 2

45. 90 palp; HR 86; SaO2 100%2L; RR 18; temp 36.9 abdomen firm, mildly tender LUQ

48. Embolization by interventional radiology Stabilises, no further transfusions Unit 71, discharged a few days later

49. Case 3 4 yo F jumped out 2 story window No VS abnormalities Obviously deformed right femur No abdominal tenderness

50. Insert XR here

51. More awake, less pain post femoral nerve block Mild generalised abdominal pain ++++ RBC on urine cath dip What to do now??

52. Objectives Hematuria in BAT

53. WHEN THE WHITE TURNS RED....

55. Microscpopic Hematuria dipstick positive >5 RBC / HPF Gross Hematuria Visible blood of any degree

56. Gross Hematuria Microspcopic hematuria and shock (SBP<90) Significant deceleration injury Suspected intra-abdominal injuries (J urol 1995;154:352)

58. Little Adults?

59. CT abdo / pelvis: No acute injury Kineys normal Admitted to ortho fracture managment

60. 22 year old M Ran over by combine wheel near High River STARS to FMC Case 4

61. 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

63. Pelvic Fracture Hemodynamically Stable? FAST / DPL Positive? Laparotomy No Angiography & Pelvic fixation Observation Yes No IPH? FAST, CT, DPL Yes

64. FAST in pelvic fractures SN 81% SP 87% What does a negative FAST mean?

65. Rt internal iliac artery embolized with coil Persistently tachycardic, hypotense Taken to OR

66. 17 yo M, aspiring Ducati racer Flipped numerous times with bike before coming to stop Wearing helmet, no leathers Case 5

67. HR 119; BP 135/80; RR16; SaO2 99% 2L Abdomen is +++tender – road rash over abdomen, torso, extremities FAST negative

68. We decide to scan his abdo/pelvis Free fluid on 3 slices no identifiable intra-abdominal organ damage

69. Free Fluid Undetected solid organ injury Bowel injury Mesentery injury

70. 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”

72. CT scan normal, no free fluid, nil acute Reassess frequently, more sober, still tender. Observed until end of shift, tenderness dissipated, vital signs stable.

73. Negative CT scan Discharge Admit for observation (J trauma 1998;44:273) (Academic Emerg Med 2010;15:89

74. Discharged to Woman’s centre Decides to press charges against her boyfriend

75. Common pitfalls Objectives

76. False Negative Prediction (Emerg Med Clin N Am 2010;28:1)

77. False attribution (Emerg Med Clin N Am 2010;28:1)

78. Failure to assess the abdomen and plevis (Emerg Med Clin N Am 2010;28:1)

79. Missed injuries (Emerg Med Clin N Am 2010;28:1)