Abdominal/pelvic Trauma

Question 1

Evaluation of suspected anorectal injury?

Answer 1

EUA is the gold standard - anoscopy, sigmoidoscopy, vaginoscopy, and cystoscope as indicated.

Consider retrograde urethrogram in the presence of pelvic # as there is a 70% incidence of co-injury.

Question 2

management of extraperitoneal anorectal injuries?

Answer 2

Primary repair if possible with proximal diversion.

Question 3

Common location for blunt aortic injury?

Answer 3

Descending aorta at the ligamentum arteriosum.

Question 4

Findings of BAI on chest x-ray?

Answer 4

Wide mediastinum,
 deviation of NG to the right,
 blurred aortic knob,
 right tracheal deviation,
 abnormal paraspineal stripe

*funny looking mediastinum.

Question 5

Priority of injuries with BAI and abdominal hemorrhage?

Answer 5

Laparotomy should take priority before dealing with aorta.

Question 6

Medical mgmgt of BAI?

Answer 6

beta-blockers

Question 7

APSA 2019 Admission guidelines for SOI?

Answer 7

ICU- abnormal vitals after initial volume resuscitation.

• Bedrest until vitals normal
• q6h CBC until vitals normal
• NPO until vitals normal and Hgb stable

Ward

• AAT
• CBC on admission and 6 hours later stop when stable
• DAT

Question 8

APSA SOI 2019 intervention guidelines?

Answer 8

Transfusion - vitals unstable after 20/kg RL

• Hgb <70
• signs of ongoing bleeding

Angio - ongoing bleeding in stable patient
* not for contrast blush

OR - unstable vitals despite transfusion
- consider 1:1:1 transufusion

Question 9

APSA SOI discharge criteria?

Answer 9

Tolerating DAT
Minimal pain
Normal vitals

Question 10

APSA 2019 SOI follow up?

Answer 10

• limit activity to grade + 2 weeks

- follow up image symptomatic patients

Question 11

3 most common mechanisms for duodenal injury?

Answer 11

Handle bar
Lap belt
NAT - if seen in toddler or infant should be highly suspected

Question 12

AAST grading for duodenal injuries?

Answer 12

1 - hematoma involving one portion or partial thickness lac.

2- hematoma beyond one portion or < 50% disruption

3 - disruption of 50-75% of D2 or 50-100% of D1/3/4

4- disruption of > 75% of D2 or involvement of the ampulla

5 - massive disruption of duodenopancreatic complex or devascularization.

Question 13

Management of duodenal hematoma?

Answer 13

NPO, NG, TPN

• 90% resolve (usually within 2 weeks)
• Reimage at 2 weeks of still symptomatic at which point may continue observation or operate.

Question 14

Options for duodenal repair?

Answer 14

• Pyloric exclusion with G-J for grade 3/4 injuries
• Lower grade injuries can be repaired primarily.
• Roux D-J
• De rotation with primary D-J

Question 15

Should Feeding J-tube be placed after duodenal repair?

Answer 15

yes

Question 16

What is the lap belt complex of injuries?

Answer 16

Abdominal wall contusion
Chance fracture of the lumbar spine
Isolated small bowel perforation

Question 17

What is the best diagnostic modality for small bowel injury?

Answer 17

Serial abdominal exams.

Only 1/3 have free air on plain films

Question 18

AAST splenic injury grading:

Answer 18

1 - hematoma < 10% of surface or lac < 1cm deep

2- hematoma 10-50% or lac 1-3 cm deep

3- hematoma > 50 % or ruptured hematoma, lac > 3cm

4- lac involving segmental hilar vessels with > 25% devascularized spleen.

5- shattered spleen or hilar main vessel injury

Question 19

AAST liver injury grading:

Answer 19

1- hematoma < 10 % or lac < 1 cm

2- hematoma 10-50% or lac 1-3 cm deep

3- hematoma > 50% or ruptured/expanding, lac > 3 cm deep

4- parenchyma injury involving 25-75 % of a lobe.

5 - parenchyma injury involving > 75% of a lobe, or retrohepatic injury

6- hepatic avulsion

Question 20

Criteria for CT abdomen in blunt trauma:

Answer 20

Seatbelt sign
GCS < 15
Tenderness on exam or complains of pain
Decreased breath sounds
Vomiting

Question 21

Failure rate of non-op mgmgt in SOI?

Answer 21

5% - median time to failure 3 hours

76% who fail do so within 12 hours

Question 22

Chance of rebleed after discharge from hospital for SOI?

Answer 22

1 in 300 at median of 8 days

Question 23

What is the natural history of spleen and liver pseudo-aneurisms?

Answer 23

Incidence of ~17%, most thrombose without treatment.

Aneurisms from high gradeliver injuries may be higher risk for rupture.

Question 24

What is the risk of OPSI post splenectomy?

Answer 24

Overall rate is 4.4% under the age of 16

*children under 5 have a rate of 10-15%

Question 25

How is a bile leak managed post liver injury?

Answer 25

Occurs in grade 3 injuries or above ~5% of the time.

Symptoms include RUQ pain, fever, jaundice

Confirm Dx with HIDA

ERCP to stent duct with perc/lap drainage of collection

Question 26

Management of hemobilia?

Answer 26

Best managed with hepatic artery emoblization

More common with penetrating injuries.

Question 27

AAST grading for pancreatic trauma?

Answer 27

1) minor contusion or lac
2) major contusion or lac
3) Distal transection with duct injury
4) Proximal transection or parenchyma injury to ampulla
5) Massive head disruption

Question 28

Pros and Cons of pancreatectomy vs. non-op mgmt of Grade 3 pancreas injury?

Answer 28

Pros: 
Lowe pseudocyst formation
Shorter time to oral feeds
Shorter LOS
Visualization of other injuries

Cons:
Risk of splenectomy and vascular injury
Possible pancreatic insufficiency
Post op adhesions
Pancreatic fistula

Question 29

Management options for post-traumatic pseudocyst?

Answer 29

Monitor if asymptomatic
Perc drain - trans gastric
ERCP with stent
Distal pancreatectomy

Question 30

management of pancreatic fistula?

Answer 30

TPN or post ampullary feeds
Somatostatin
ERCP with stent