Abdominal and Pelvic trauma Flashcards by Thomas Eraifej

Clinical regions of the abdomen

Anterior abdomen
Thoracoabdomen
Flank
Back
Pelvic cavity

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Boundaries of anterior abdomen

Superior - costal margins

Inferior - inguinal ligaments and pubic symphysis

Lateral - anterior axillary lines

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Organs at risk in the anterior abdomen

Most solid and hollow viscera

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Boundaries of the thoracoabdomen

Superior - nipple line anteriorly, infra-scapular line posteriorly

Inferior - costal margins

No lateral boundary as runs around entire circumference of torso

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Organs at risk in the thoracoabdomen

Diaphragm
Liver
Spleen
Stomach

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Boundaries of the flank

Superior - 6th intercostal space
Anterior - anterior axillary line
Posterior - posterior axillary line
Inferior - iliac crest

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Organs at risk in the flank

Most hollow viscera
Diaphragm
Liver / spleen
Stomach

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Boundaries of the back

Superior - tip of the scapulae
Lateral - posterior axillary lines
Inferior - iliac crests

Includes the posterior thoracoabdomen and retroperitoneal space

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Organs at risk in the back

Aorta + Vena cava
Duodenum
Pancreas
Kidneys + Ureters
Retroperitoneal parts of ascending / descending colon

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Boundaries of the pelvic cavity

Pelvic bones

Contains lower part of the retroperitoneal and intraperitoneal spaces

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Organs at risk in the pelvic cavity

Rectum
Bladder
Iliac vessels
Internal reproductive organs (females)
Blood loss from bony pelvis

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Forms of blunt trauma

Direct blow
Shearing forces
Deceleration

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Direct blow consequences

Can cause:
- Compression and crushing injuries
- Rupture
- Secondary haemorrhage
- Contamination by visceral contents

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Shearing forces mechanism

Can result from use of restraints and cause crushing injury

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Deceleration forces mechanism

Differential movement of fixed and mobile parts of the body

Can cause tears at fixed points

(eg. liver and spleen which are mobile organs tethered at fixed points by supporting ligaments)

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Injuries associated with lap seat belt restraint

Tear / avulsion of bowel mesentery
Rupture of bowel
Iliac artery / aortic thrombosis
Lumbar vertebra “Chance” fracture
Pancreatic / duodenal injury

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Lumbar vertebral chance fracture

Caused by flexion-distraction injury

Unstable

Horizontal fracture through spinous process, pedicles and vertebral body

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Injuries associated with shoulder harness restraints

Upper abdo viscera rupture

Tear / thrombosis of carotid, subclavian or vertebral arteries

C spine fracture / dislocation

Rib fracture

Pulmonary contusion

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Injuries associated with air bag use

Face and eye abrasions

Cardiac injuries

Spine fractures

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Mechanism of injury with low energy penetrating trauma (inc low energy gunshot wounds)

Tissue damage from lacerating and tearing

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Mechanism of injury with high energy penetrating trauma (inc high energy gunshot wounds)

Additional tissue damage due to trajectory, cavitation effect and bullet fragmentation

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Mechanisms of injury associated with explosions

Penetrating fragment wounds

Blunt injuries from being thrown

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Physical examination findings which suggest pelvic fractures

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Ruptured urethra (scrotal haematoma or blood at urethral meatus

Discrepancy of limb length

Rotational leg deformity with no clear fracture

How frequently should pelvis be assessed for mechanical stability

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Not at all as may disrupt existing blood clot

Assume instability of pelvic ring where pelvic fracture suspected

Use pelvic binder

Useful information in patient Hx for motor vehicle crash

Speed Collision type Intrusion into passenger compartment Ejection Restraint type Air bag deployment Patient position Status of other passengers

Useful information in patient Hx for falls

Height of fall

Useful information in patient Hx for penetrating trauma

Time of injury Type of weapon Distance from assailant Number of stab / gunshot wounds Amount of external blood at scene

Useful information in patient Hx for explosion

Distance from explosion Enclosed or open space Secondary impact (eg thrown / fall) Secondary projectiles

Important evaluation in pregnancy with abdo trauma

Estimate foetal age

Benefit from using a pelvic binder

Reduces pelvic radius and therefore reduces potential space available for blood loss

Methods of haemorrhage control from pelvic fracture in ED

Stabilisation with: - Pelvic binder (at level of greater trochanters) - Sheet - Internal rotation of lower limbs

Methods of definitive haemorrhage control in pelvic fractures

Surgery Angiographic embolization

Contraindication to bladder catheterisation

Perineal haematoma or blood at urethral meatus before definitive assessment for urethral injury

When to perform rectal, vagina or gluteal examination

Bony fragments from pelvic fracture or penetrating injury suspected

Goal of gastric tube placement in trauma patients

Relieve gastric dilatation and decompress stomach

Blood in gastric contents of gastric tube

Suggests oesophageal or upper GI injury

Contraindication to NG tube

Facial fractures Basal skull fractures

Options when NG tube contraindication

Insert gastric tube through mouth (Orogastric tube rather than Nasogastric tube)

Goals of urinary catheterisation

Identify bleeding Monitor UO Decompress bladder (wait until after FAST scan if can)

Which patients require retrograde urethrogram

Cannot void bladder Require pelvic binder Blood at urethral meatus Scrotal haematoma Perineal ecchymosis

Most common cause of free fluid in abdomen with abdominal organs intact on CT

Mesenteric tears Bowel rupture

Seat-belt sign

Have high suspicion of bowel injury

XR to perform in Haemodynamically Abnormal patient with penetrating abdominal trauma

No screening X rays

XR to perform in Haemodynamically Normal patient with penetrating abdominal trauma - wound above umbilicus or suspected thoracoabdominal injury

Erect CXR

XR to perform in Haemodynamically Normal patient with penetrating abdominal trauma - with gunshot wound(s)

Supine abdo XR

Advantages of FAST scan

Early operative determination Non-invasive Repeatable Rapid

Disadvantages of FAST scan

Operator dependant Bowel gas / body habitus can distort images Can miss diaphragm or pancreas injury Does not fully assess retroperitoneal structures

Goal of diagnostic peritoneal lavage (DPL)

Rapidly identify intraperitoneal bleeding and need for operation

When is DPL most useful

Haemodynamically Abnormal patients with: - Blunt abdo trauma - Penetrating abdo trauma without indication for immediate laparotomy Can be performed in resuscitation area

Disadvantages with DPL

Invasive Requires surgical expertise

Relative contraindications to DPL

Previous abdo surgery Morbid obesity Advanced cirrhosis Pre-existing coagulopathy

Indications for immediate emergency laparotomy in patients with penetrating abdominal wounds

Any haemodynamically abnormal patient Gunshot wound with transperitoneal trajectory Peritonitis Signs of peritoneal penetration (eg. evisceration) Free / extra-luminal air on imaging Retained stabbing implement Positive FAST / DPL / CT Blood per gastric, rectal or genitourinary tract

Indications for immediate emergency laparotomy in patients with blunt abdominal trauma

Haemodynamically abnormal with positive FAST / DPL or suspected abdo injury Positive CT scan and haemodynamic status not improving Extra-luminal air on imaging Evidence of diaphragm rupture Evidence of intraperitoneal bladder rupture Peritonitis

When to suspect blunt hollow viscus injuries

Sudden deceleration mechanism Seat-belt sign Lumbar chance fracture Abdo pain / tenderness

When to suspect blunt duodenal injuries

Unrestrained driver in front impact crash Direct abdominal blow Blood in gastric aspirate Retroperitoneal air on imaging

Mechanism for blunt pancreatic injuries

Compression of pancreas against vertebral column From direct epigastric blow

Abdominal and Pelvic trauma Flashcards

(56 cards)