38. Abdo Trauma

Question 1

Most likely organs to sustain penetrating trauma?

Answer 1

sm intest
colon
liver

Question 2

MC organ injured in blunt trauma?

Answer 2

splen
liver second

Question 3

What is the anterior abdomen?

Answer 3

region between anterior axillary lines from costal margins to groin creases

Question 4

Low chest defn

Answer 4

nipple line or 4th ICS ant, inferior scapula tip or 7th IC posteriorly and extends down to inferior costal margins

Question 5

Flank defn

Answer 5

ant and posterior axillary lines bilaterally inf scapula to tip of iliac crest

Question 6

Gun shot wounds - what is the concerning physicss of E?

Answer 6

= 700mv^2/ 2 ga (ga = gravit accel)

Question 7

Gun shot wounds - high vs low velocity impact?

Answer 7

low <1100 ft/s high - faster than 2000-2500

Question 8

Most important determinations of firearm injuries?

Answer 8

distance firearm and victim
muzzle v
characteristics of projectile

Question 9

Shotgun wounds vs other projectile injuries

Answer 9

type of shot and distance from the victim

Question 10

Seat belt injuries - hoe fo these occur?

Answer 10

compression bowel between belt and VC- contusion or perforation or intestines or mesentary tear

Question 11

What is the seat belt sign?

Answer 11

contusion along lower abdomen - high correlation with intraperitoneal pathologic lesions

recommended further imaging

Question 12

What is helpful to gauge severity of injury in penetrating abdo trauma/stab wounds:

Answer 12

number
type and size
instrument
posture of victim relative to direction of assault
EBL
time of injury
response to fluids

Question 13

Triad of injuries to what areas is concerning for pathologic lesions?

Answer 13

torso
cranium
lower extremity

Question 14

Uunexplained hypotension accompanies signifi- cant blunt trauma, one should assume the presence of..

Answer 14

intraperitoneal hemorrhage

Question 15

Gray Turner signs

Answer 15

ecchymotic discoloration of the flanks

= retroperitoneal hemorrhage

Question 16

Cullen sign

Answer 16

umblicus ecchymotic discoloration

= retroperitoneal hemorrhage

Question 17

Overall, the accuracy of the physical examination in patients with blunt abdominal trauma is only _% - % because the initial presentation may be deceptively benign

Answer 17

55% to 65%

Question 18

DDX from abdo trauma:

Answer 18

solid or viscous organ injury, vascular injuries, intra-abdominal bleed- ing, abdominal compartment syndromes (ACSs) or retroperitoneal hematomas. Injury to the abdominal aorta can result in mortality up to 50% to 70%

Question 19

The hematocrit can represent a baseline value but is also a function of the extent of and time from hemorrhage, exogenous fluid adminis- tration, and endogenous plasma refill. How is this helpful?

Answer 19

Patients with hemorrhagic shock (at least 40%) demonstrate much faster plasma refill rates, with significant decreases in hematocrit within 90 minutes. Hematocrit val- ues often represent a conundrum when viewed in isolation but are use- ful when measured serially.

Question 20

Labs for abdo trauma

Answer 20

cbc
vbg-lactate
LE
etoh

*lipase no longer helpful

Question 21

When is AXR useful in blunt abdo trauma?

Answer 21

free intraperitoneal air
FB and projectiles

Question 22

limitations of abdo CT - which organs?

Answer 22

pancreas
diaphragm
small bowell
mesentary

Question 23

Placement of an __gastric tube is preferable in patients with midface or skull base fractures.

Answer 23

oro

Question 24

Alternative for an ED thoractomy?

Answer 24

REsus endovascular balloon occlusion (REBOA)

Question 25

Perforated hollow viscous injuries - abx?

Answer 25

piperacillin-tazobactam 3.375 g intravenously, is recommended in the setting of perforated hollow viscus injuries.

Question 26

Penetrating anterior abdo trauma: Emergent laparotomy indications: 4

Answer 26

1. HD compromise 2. Peritoneal signs 3. Evisceration 4. L sided diaphragm injury

Question 27

Penetrating injuries: laparotomy only considered with what additional clinical evidence: 3

Answer 27

1. with gastric hemorrhage from NG tube 2. implements in situ 3. intraperitoneal air

Question 28

If clinical indications for lap from penetrating trauma are absent: assess wound itself: indications for lap? 5

Answer 28

1. eviceration of bowel/omentum 2. intraperitoneal free air on CXR 3. Local wound exploration: unclear if small puncture, long tangential wund, multiple wound or obese 4. U/s - efast + 5. Lap or thoracoscopy in OR for LWE

Question 29

Equivoval signs of diaphragmatic injury - how to manage?

Answer 29

these can be difficult to see consider OR f/u

Question 30

What is renal injury imaging of choice in penetrating injury?

Answer 30

CT with IV contrast

Question 31

3 signs in penetrating injury a patient should be taken for urgent lap

Answer 31

If the patient is hemodynamically unstable, has peritonitis, or has an unreliable abdominal exam, the patient is taken for emergent laparotomy.

Question 32

The decision to perform immediate laparotomy after injury from a blunt mechanism is reserved for patients with the following findings: 3

Answer 32

1. Refractory hypotension in a patient with positive e-FAST examina- tion for hemoperitoneum and absence of an unstable pelvic fracture 2. Obvious peritonitis with positive e-FAST examination 3. Evidence on e-FAST of intra-abdominal injury in the context of other life-threatening injuries, such as uncontrollable chest hemorrhage, which require transfer to the operating room In patients who are hemodynamically stable, CT scanning is the diagnostic modality of choice, as outlined earlier.

Question 33

Clinical indicationsc for laparotomy after blunt trauma - 5

Answer 33

unstable VS with strongly suspected abdo injury unequivocal peritoneal irritation pneumoperitoneum evidence of diaphragmatic injury sign GIB

Question 34

Pelvic fracture: lap vs observe

Answer 34

pelvic # - HD unstable, fast + if angio shows IP injury

Question 35

Combined abdo trauma and blunt head trauma algorithm: management

Answer 35

airway and ICP manage HD unstable with IPH/+ fast - Lap consideration prior to head ct if no lateralizing signs vs head ct and cranio consideration HD stable: check for laterliing signs and consider head ct/cranio if +, if negatvie can abdo CT

Question 36

Combination wide mediastinum, blunt abdo trauma algorithm: how to manage?

Answer 36

wide mediastinum - initial resus HD unstable: yes - look for intraperitoneal hemorrhage sign or + fast and lap with intraop TEE/AG if not HD unstable - ct chest and abdo

Question 37

What is REBOA for?

Answer 37

performed at bedside to decr ongoing intra-abdo or pelvic exsanguination while increasing proximal perfusion pressure

Question 38

How to place REBOA device?

Answer 38

access proximal to femoral a balloon adv to thorax in distal subclavian for intraabdo bleed or inferior to renal a for pelvic bleeding

Question 39

When to use therapeutic angiography for abdo injury?

Answer 39

unstable pt with blunt trauma and pelvic - when can see vessels -consideration for splenic injuries

Question 40

1. The extended focused assessment with sonography for trauma (e-FAST) scan of a patient with blunt abdominal trauma shows a hypoechoic stripe in the pouch of Douglas. Which of the following is correct? a. In the presence of hemodynamic instability, this indicates a need for laparotomy. b. The patient needs to go for emergent laparotomy immediately. c. The patient requires repeat abdominal examinations and FAST examinations in the emergency department (ED). d. There is at least 500 mL free fluid in the abdomen. e. This indicates a ruptured bladder.

Answer 40

A

Question 41

. An 18-year-old man presents after a high-velocity front-end vehicle collision. He has a blood pressure of 90/70 mm Hg, heart rate of 120 beats/min, respiratory rate of 17 breaths/min, and a Glasgow Coma Score (GCS) of 13. On physical examination, he has a tender abdomen and an unstable pelvis. An extended focused assessment with sonography for trauma (e-FAST) examination is positive for free fluid in the abdomen. What should be the patient’s disposition? a. Admission to the trauma service for observation b. Emergency department (ED) observation for 12 hours with repeat FAST examinations c. Interventional radiology for pelvic angiography and emboliza- tion d. Operating room for emergency laparotomy

Answer 41

D

Question 42

3. A 27-year-old male presents 4 hours after an isolated stab wound to the anterior abdomen. His vital signs are heart rate 84 beats/min and blood pressure 115/64, and the lactate level is 0.9 mg/dL. His extended focused assessment with sonography for trauma (e-FAST) examination is negative for free fluid. He denies alcohol and drug use and appears clinically sober. Which of the following statements regarding this patient’s subsequent management is true? a. A negative computed tomography (CT) scan rules out the need for further evaluation. b. If local wound exploration (LWE) definitively demonstrates that the wound does not violate the peritoneum, the patient can be discharged from the emergency department (ED). c. The negative e-FAST examination rules out intra-abdominal injury requiring operative intervention. d. The patient meets criteria for emergent laparotomy.

Answer 42

B

Question 43

5. Which of the following statements regarding splenic injuries in blunt abdominal trauma is true? a. A computed tomography (CT) scan with a grade IV splenic lac- eration indicates the need for laparotomy. b. Angiographic embolization has no role in high-grade splenic lacerations. c. Bedside extended focused assessment with sonography for trauma (e-FAST) can accurately rule-out splenic injury. d. CT scanning followed by serial abdominal examinations and hematocrits is a reasonable management option for certain splenic injuries at experienced centers. e. Mononucleosis increases the risk of splenic laceration from seemingly minor blunt abdominal trauma.

Answer 43

d

Question 44

4. A 67-year-old female who is taking warfarin for atrial fibrillation presents after a high-mechanism motor vehicle collision. Her heart rate is 142 beats/min and blood pressure is 84/40 after 1 L of normal saline. Her Glasgow Coma Score (GCS) is 6, and her left pupil is 6 mm versus 3 mm on the right. Her physical examination is notable for a seat belt sign on the abdomen. Which of the following is not an acceptable approach to her initial assessment and treatment? a. Perform an extended focused assessment with sonography for trauma (e-FAST) examination to evaluate for the presence of intra-abdominal fluid. b. Perform chest and pelvic radiographs in the resuscitation bay. c. Perform empirical craniotomy concurrently with laparotomy in the operating room after a positive diagnostic peritoneal aspira- tion. d. Perform endotracheal intubation and begin mild hyperventila- tion. e. Proceed to radiology for an emergent abdominal computed tomography (CT) scan.

Answer 44

e