1. Chapter 5

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

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

4.  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?

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

6. Flank Do not forget the back!

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

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

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

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

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

12.  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

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

14.  Inspection  Auscultation  Percussion  Palpation

15.  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?

16.  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

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

18.  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

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

20.  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

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

22.  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