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Flashcards in Abdominal Trauma Deck (70):
1

Right Upper Quadrant Structures

Liver
Gallbladder
Ascending and transverse colon

2

Left Upper Quadrant Structures

Spleen
Stomach
Left lobe of the liver
Left colonic flexure
Transverse colon

3

Left Lower Quadrant Structures

Sigmoid Colon
Portion of descending colon
Portion of duodenum

4

Right Lower Quadrant Structures

Cecum
Appendix
Portion of ascending colon

5

Retroperitoneum

Posterior to the "true abdomen". Contains aorta, inferior vena cava, pancreas, kidneys, ureters, ascending and descending colon and duodenum.

6

Types of Solid Organs

Liver, Spleen, Kidneys, and Pancreas

7

Types of Hollow Organs

Gallbladder, Stomach, Small intestine, Large intestine, Bladder

8

Abdominal vasculature

abdominal aorta, common iliac arteries, femoral arteries, renal arteries, portal vein, inferior vena cava

9

Contraindications to NG placement

nasal, midface or cribiform plate fracture

10

Contraindications to Foley placement

blood at urinary meatus, high riding prostate, perineal hematoma, concurrent pelvic injury or fracture

11

Inspection of abdomen includes

Observe for gross abnormalities, Contour, Symmetry, Visible Pulsations, Skin color/discolorations, back and flank, pelvic or perineal bleeding/drainage, general respiratory rate, pattern and depth; change in respiratory effort.

12

Contour

Rounded, flat, scaphoid, distended or pregnant if distended think of 6Fs.
Fluid, Fat, Flatus, Feces, Fetus, Fibroid.

13

Decreased and absent bowl sounds general indicate......

peritoneal irritation from enteric contents, bile, pancreatic juice, or intraperitoneal blood. May also cause ileus.

14

Borborygmi

hyperactive bowel sounds

15

Bowel sounds in the chest

diaphragmatic rupture

16

Vascular sounds in the abdomen

A bruit can be noted if artery is partially occluded

17

Percussion Sounds
(Dull vs Tympanic)

Dull: Organ margins, accumulation of free fluid
Tympanic: Air, gas

18

Balance's Sign

shifting of dullness over LUQ when patient lies on left side; suggestive of splenic rupture.

19

Pulsatile/Palpable masses are emergent if found were?

Slightly left of umbilicus

20

Other tests for rebound tenderness

Cough tenderness, percussion, heel drop test,

21

Heel drop test AKA...

Markel sign

22

What is heel drop test

Have pt stand on their toes and drop their heels. If this aggravates the pain, consider it positive. Same test on a supine patient. Gently pick up the leg and tap the heel. If pt winces, suspect peritoneal inflammation

23

Prostate location can indicate...

presence of urethral tear

24

Peritoneal irritation signs

board-like abdomen described as increased rigidity of the abdominal wall or palpable rigidity.
Diminished or absent bowel sounds
Involuntary guarding
Sever focal pain, rebound tenderness

25

Kehr's Sign

Referred pain in the left shoulder suggest peritoneal or diaphragmatic irritation; usually noted with splenic rupture.

26

Cullen's sign

Bluish discoloration around the umbilicus suggests intra or retroperitoneal hemorrhage

27

Grey-Turner's Sign

Discoloration of the lower abdomen and flanks is believed to believed to be due to the infiltration of etraperitoneal tissues with blood. Seen in acute hemorrhagic pancreatitis or renal trauma.

28

On KUB, Loss of Psoas shadow suggests...

retroperitoneal injury

29

CT advantages

IDs BOTH intraperitoneal and retroperitoneal injuries. Both qualitative and quantitative (Id of injured organ as well as blood loss), can be repeated as often as necessary, not complicated by peritoneal irritation, not limited by intestinal gas, can assess vascular integrity with contrast

30

CT disadvantages

Need for contrast, potential for allergy, need for adequate hydration for tenal perfusion, need to move pt to radiology, time, cost. May miss GI injuries, diaphragm, and pancreatic injuries.

31

Diagnostic peritoneal lavage (DPL) Advantages

Rapid and simple, Accurate (highly sensitive for bleeding 98%), inexpensive, patient doesn't need to leave the unit

32

Diagnostic Peritoneal Lavage (DPL) Disadvantages

Invasive, Low specificity (cannot quantify hematomas or judge amount or location of bleeding)

33

Nursing Implications of DPL

ABCs take priority, Place gastric tube and urinary prior to insertion unless contraindicated. Get films prior to testing as free air can be introduced

34

Absolute indications for exploratory laparotomy

Persistent and/or recurring shock w/o an identifiable source (suspect abdominal injury), evisceration, peritonitis, frank blood per gastric rube or rectum, frank blood per gastric tube or rectum, free air or retroperitoneal air on XR, retained stabbing implement, positive ancillary tests, suspected diaphragmatic rupture, intraperitoneal bladder rupture, free fluid on CT scan without evidence of solid organ injury. S

35

REBOA

Resuscitative Endovascular Balloon Occlusion of the Aorta.
Aortic occlusion temporarily controls distal bleeding until permanent hemostasis is provided. Used to increase SBP and augment perfusion to heart and brain.

36

PQRST pneumonic

P:What provokes or palliates the pain
Q: Quality of the pai
R: Region, radiation, recurrence
S: severity 0-10
T:Time- onset and duration

37

Classification of Liver Hematoma ( I - IV)

Grade I (subcapsular) to Grade IV (ruptured central hematoma)

38

Classification of Liver Laceration ( I - IV)

Grade I (capsular tear, nonbleeding) to Grade IV (parenchymal destruction of 25% - 75% of hepatic lobe)

39

Grade V Liver

Laceration: >75% of hepatic love destruction
Vascular: juxtahepatic venous injuries

40

Grade VI Liver

Hepatic avulsion

41

Clinical Presentation of Liver injuries

peritoneal irritation, RUQ guarding w/ radiation to right shoulder, right diaphragm elevation, lower right rib fx, volume deficit and shock, decreased HCT increased WBC, frequently associated with brain trauma.

42

Indications for laparotomy

Hemodynamically unstable patients who have sustained blunt abdominal trauma or who have diffuse peritonitis or evidence of ongoing hemorrhage should be taken urgently for a laparotomy

43

What is the most commonly injures organ in blunt abdominal trauma?

Spleen

44

Classification of Spleen Hematoma (I - IV)

Grade I: subscapsular, nonexplandind; Grade IV: Ruptured, intraperitoneal bleeding

45

Classification of Spleen Laceration (I-IV)

Grade I: Noncapsular tear, nonbleeding; Grade IV: Segmental or hilar vessel that produces major devascularization.

46

Grade V Spleen Injury

Laceration: Completely shattered spleen
Vascular: Hilar vascular injury that devascularizes spleen

47

Management of blunt Splenic injuries

Non-operative management is indicated in 85% of pt with blunt splenic injuries. A routine laparotomy is not indicated in patient who have an isolated splenic injury and are hemodynamically stable and do not have peritonitis.

48

High risk patients for failure of non-operative management include...

patients with a vascular blush or pseudoaneurysm on CT scan.

49

Pts with non-surgical management should be educated for the possibility of?

delayed splenic rupture when discharged home.

50

OPSS

Overwhelming Post-Splenectomy Sepsis
Greatest risk for this condition occurs within the first 2 years post splenectomy. Mortality is high unless early identification and aggressive treatment occurs.

51

Treatment OPSS

Early goal directed therapy for sepsis is recommended along with administration of vancoymcin and ceftriaxone

52

Prevention of OPSS

Post-splenectomy patients are immunized with pneumococcal, meningococcal, and hemophilus influenza vaccines.
Additionally, the pt/family should be taught s/s of OPSS and a medic-alert bracelet should be worn

53

What organ is most injured in penetrating trauma

small bowel

54

Rapid deceleration increases injury of what organ and why?

Pancreas because first portion if fixed in the peritoneum, anchor to posterior wall and small portion of the stomach. Rapid deceleration results in rupture between free and anchored portions.

55

Duodenal injuries

direct blow to abdomen
fixed at one end; easily town in high speed deceleration. may crush against vertebrae causing sever contusion and laceration.

56

Management of colon/rectal trauma

Early use of antibiotics is essential!

57

Diaphragm injuries

Seen in less than 5% of trauma. Increases with age. Risk is increased in lateral impact. Left side is more commonly injured.
Resembles pneumothorax.

58

Hamman's sign

A rasping sound, synchronous with the heartbeat, occurring in pneumomediastinum. Associated with esophageal injuries

59

Most frequent truncal vascular injuries are...

injuries to the inferior vena cava

60

Clinical presentation of Vascular injuries

Pt may arrive alert with normal BP and HCT and crash.

61

Management of Vascular injuries

Rapid infusion of warmed blood products and crystalloids, avoidance of hypothermia, abdominal exploration: initial tamponade using manual compression and lap packs with hepatic inflow occlusion

62

"Damage Control"

refers to an abbreviated laparotomy to save trauma patients who have sustained abdominal vascular injury, massive shock, hypothermia, and acidosis. Has 3 phases

63

3 Phases of Damage Control

1: Resuscitative surgery for rapid control of hemorrhage
2: Transfer to ICU
3: re-exploration is done to provide definitive management

64

Abdominal compartment syndrome is....

intra-abdominal hypertension
Pressure is >20mmHg
Massive fluid resuscitation can lead to increased intra-abdominal pressure.

65

Open abdomen is mandated if

pulmonary deterioration on closure of abdomen, hemodynamic instability with closure of abdomen, massive bowel edema, selectively tight closure, planned reoperation or intra-abdominal packing

66

Leaving Abdomen open is discretionary if:

fecal contamination or peritonitis is present, massive transfusion has occurred, the pt is hypovolemic, had multiple intra-abdominal injuries, persistent acidosis, or coagulopathy

67

clinical indicators that should lead to suspicion of ACS

reduction in gastic pH, increased bladder pressure, persistent or worsening acidosis without other causes, increase in O2 requirements, increased airway pressures, reduced cardiac output, persistent or worsening oliguria.

68

Possible complication if ACS foes unrecognized

renal failure, abdominal wall ischemia/edema, respiratory failure, intracranial hypertension, intestinal hepatic ischemia

69

Bladder pressure

18-22mmHg is considered elevated

70

Treatment of ACS

includes decompression of the abdomen by repeat celiotomy and leaving the abdomen open with an artificial covering to keep the abdominal contents sterile and maintain as normal an intra-abdominal environment as possible. Wound vacs used as temporary wall closure