Chapter 5 - Abdominal and Pelvic Trauma Flashcards
(91 cards)
1
Q
What should be assumed if a patient has sustained significant blunt torso trauma from a direct blow, deceleration or a penetrating injury?
A
Injury to the abdominal viscera, vasculature or pelvis until proven otherwise.
2
Q
Define the landmarks of the anterior abdomen.
A
The area between the costal margins superiorly, the inguinal ligaments and the symphysis pubis inferiorly, and the anterior axillary lines laterally.
3
Q
Define the landmarks of the thoraco-abdomen.
A
The area inferior to the trans-nipple line anteriorly and the infra-scapular line posteriorly, and superior to the costal margins. This area include the diaphragm, liver, spleen and stomach.
4
Q
Define the landmarks of the flank.
A
The area between the anterior and posterior axillary lines from the sixth intercostal space to the iliac crest.
5
Q
Define the landmarks of the back.
A
The area located posterior to the posterior axillary lines from the tip of the scapulae to the iliac crests.
6
Q
Where are the retroperitoneal organs contained?
A
In the flank and the back.
7
Q
What organs are in the retroperitoneum?
A
1/ Abdominal aorta 2/ Inferior vena cava 3/ Most of the duodenum 4/ Pancreas 5/ Kidneys 6/ Ureters 7/ The posterior aspects of the ascending and descending colons 8/ The retroperitoneal composition of the pelvic cavity.
8
Q
Why are injuries to the retroperitoneum hard to recognise?
A
The area is remote from physical examination and the injuries may not initially present with signs or symptoms of peritonitis.
9
Q
What organs are in the pelvic cavity?
A
1/ Rectum
2/ Bladder
3/ Iliac vessels
4/ Internal reproductive organs (in females)
10
Q
What is the definition of a deceleration injury?
A
It is an injury where the is a different movement of fixed and nonfixed parts of the body.
11
Q
Give some examples of deceleration injuries?
A
1/ Lacerations of the liver and spleen.
2/ Bucket handle injuries to the small bowel.
12
Q
What organs are most frequently injured in blunt trauma to the abdomen?
A
1/ Spleen (40-55%)
2/ Liver (35-45%)
3/ Small bowel (5% to 10%)
13
Q
What kind of injuries can you get from a lap seat belt?
A
- Tear of avulsion of the mesentery (Bucket Handle Tear)
- Rupture of the small bowel or colon.
- Thrombosis of the iliac artery or abdominal aorta
- Chance fracture of lumbar vertebrae.
- Pancreatic or duodenal injury
14
Q
What kind of injuries can you get from a shoulder harness?
A
- Intimal tear or thrombosis in innominate, carotid,subclavian or vertebral arteries.
- Fractures or dislocations of the C-spine.
- Rib fractures.
- Pulmonary contusion.
- Rupture of upper abdominal viscera
15
Q
What kind of injuries can you get from an airbag?
A
- Corneal abrasion
- Abrasions to the face, neck or chest.
- Cardiac rupture
- Cervical spine injury
- Thoracic spine fracture
16
Q
When can shearing injuries occur in the car?
A
When a restraint device is worn improperly
17
Q
What general sort of injuries can a direct blow to the abdomen cause?
A
- Compression/Crushing injuries
- Abdominal viscera and pelvis
- Organ rupture +/- secondary hemorrhage
- Contamination by visceral contents +/- peritonitis.
18
Q
What organs do stab wounds most commonly involve?
A
- Liver (40%)
- Small bowel (30%)
- Diaphragm (20%)
- Colon (15%)
19
Q
What organs do gunshot wounds most commonly involve?
A
- Small bowel (50%)
- Colon (40%)
- Liver (30%)
- Abdominal structures (25%)
20
Q
What two factors affect the injuries incurred by a gunshot wound?
A
- The type of shot
- The distance from the gun.
21
Q
What is an overpressure injury?
A
This is an injury related to the blast from an explosion
If in an enclosed space, the likelihood of overpressure injury increases..
There may be penetrating objects from the blast or purely from the barotrauma of the explosion.
Pulmonary and hollow viscouses are commonly affected.
22
Q
What sort of injuries can result from wearing a lap seat belt?
A
- Bucket handle tear- Tear or avulsion of mesentery.
- Rupture of small bowel or colon
- Thrombosis of iliac artery or abdominal aorta
- Fracutred lumbar vertebrae
- Pancreatic or duodenal injury
23
Q
What injuries can result form wearing a shoulder harness?
A
- Intimal tear or thrombosis in innominate, carotid, subclavian or vertebral arteries.
- Fracture or dislocation of cervical spine.
- Rib fractures
- Pulmonary contusion
- Rupture of upper abdominal viscera
24
Q
What injuries can result from an air bag?
A
- Corneal abrasions
- Abrasions of face, neck and chest
- Cardiac rupture
- Cervical spine
- Thoracic spine fracture.
25
What history should be taken when assessing a patient in a motor vehicle accident?
1. Speed of the vehicle
2. Type of collision (frontal, lateral, sideswipe, rear impact or rollover)
3. Vehicle intrusion into the passenger compartment.
4. Types of restraints.
5. Deployment of air bags.
6. Patient's position in the vehicle
7. Status of passengers.
26
What history should be taken when assessing a patient who has fallen?
1. The height of the fall.
27
What history should be taken when assessing a patient who has penetrating trauma?
1. Time of injury
2. Type of weapon
3. Distance from assailant. (Beyond 10 feet/3 metres the likelihood of major visceral injury decreases substantially.)
4. Number of stab/shot sustained.
5. Amount of external bleeding at the scene.
28
What are the steps of the secondary abominal examination?
1. **Inspect** for anterior & posterior abdomen for signs of blunt and penetrating inury & internal bleeding.
2. **Auscultate for the presence of bowel sounds.**
3. **Precuss** the abdomen to elicit subtle rebound tenderness.
4. **Palpate** the abdomen for tenderness, involuntary muscle guarding, unequivocal revound tenderness and a gravid uterus.
5. Assess for **pelvic stability** & obtain pelvic xray if required.
6. **Perineal exam** - contusions, hematomas, lacerations and urethral bleeding.
7. **Rectal exam** - blood, spinchter tone, bowel wall integrity, bony fragments, prostate position.
8. **Gluteal exam**
9. **Vaginal Exam** - lacerations and blood in vaginal vault.
29
* Blood at the urethral meatus
* Scrotal haematoma
* Laceration of the perineum, vagina, rectum or buttocks
* A high riding prostate
* Limb length discrepancies/deformity
Are all suggestive of what?
Open pelvic fracture.
30
If bowel sounds are absent on auscultation what could this signify?
Ileus secondary to Free GI contents or intraperitoneal blood.
31
On mild percussion, we are looking for signs of peritoneal irritation. If peritonism is seen should we also test for rebound tenderness?
NO!!! This will cause the pt more pain.
32
Why do we perform a manual manipulation of the pelvis only once?
To prevent further dislodging of clots and haemorrhage.
33
When should the manual manipulation of the pelvis NOT be performed?
1. Shock
2. Obvious pelvic fracture
34
Describe the compression distraction maneuver?
The Iliac crests are grasped and the unstable hemipelvis is pushed/rotated inward(internally) and then outward(externally).
35
When testing the pelvis for posterior ligamentous disruption (shear fracture), what manipulation can you do?
The hemipelvis can be pushed cephalad as well as pulled caudally. You simultaneously palpate the posterior iliac spine and tubercle
36
Blood at the urethral meatus strongly suggests what 2 injuries?
1. Urethral Meatus injury
2. Pelvic fracture
37
What are your goals when performing a rectal examination?
1. Assess spincter tone
2. Assess rectal mucosal integrity
3. Determine position of prostate (e.g. high riding)
4. Identiy any fractures of the pelvic bone.
5. Look for gross blood (especially if penetrating wound)
38
If someone has a high riding prostate or a scrotal/perineal hematoma what should you NOT do?
DO NOT insert Foley catheters.
They may have a urethral injury.
39
Penetrating injuries of the gluteal area are associated with (?) incidence of significant intraabomdinal injury?
50%
40
What are the therapeutic goals of inserting gastric tubes?
1. Relieve acute gastric dilation
2. Decompress the stomach before performing DPL
3. Remove gastric contents.
41
What does the presence of blood upon NG insertion suggest?
Injury to the oesophagus or upper GI tract.
42
What are the goals of **Urinary Catheter** insertion?
1. Relieve retention
2. Decompress the bladder before performing DPL.
3. Allow for monitoring urinary output (e.g. monitor tissue perfusion.)
43
What is gross haematuria a sign of?
Trauma to the genitourinary tract and non-renal intraabominal organs.
44
You **would NOT** insert a **catheter** and would do a urethrogram if you saw any of the following signs?
1. The inability to void
2. Unstable pervlic fracture
3. Blood at the meatus
4. Scrotal haematoma
5. Perineal ecchymoses
6. High riding prostate on PR
45
If you do have a disrupted urethra what procedure can you do to relieve the bladder?
Suprapubic catheter insertion.
46
What is the only contraindication to performing a FAST Scan or a DPL?
Existing indication for laparotomy
47
In what conditions may you need further studies?
1. **Change in sensorium** (**potential brain injury**, alcohol intoxication or use of illicit drugs)
2. **Change** in **sensation** (potential injury to **spinal** **cord**)
3. **Injury to adjacent structures**, such as the lower ribs, pelvis or lumbar spine.
4. **Equivocal physical examination**
5. **Lap belt sign** (**abdominal wall contusion**) with **suspicion** of **bowel injury**.
48
With penetrating wounds, what should you put at all entrance and exit sites when performing an x-ray?
Marker rings/clips.
49
The FAST scan is used to obtain views of ?
1. Cardiac Tamponade
2. Hepatorenal fossa
3. Splenorenal Fossa
4. Pelvis
5. Puch of Douglas
50
What does DPL stand for & how sensitive is it for detecting intraperitoneal bleeding?
Diagnostic peritoneal lavage. 98% sensitive
51
Name some relative contraindications to DPL?
1. Previous abdominal operations
2. Morbid obesity
3. Advvanced cirrhosis
4. Preexisting coagulopathy
52
If blood, GI contents, vegetable fibers or bile are obtained through DPL, what needs to be done?
Laparotomy.
53
Are DPL's usually done infrapubically or suprapubically?
Infrapubically.
However, if a pelvic fracture is suspected then it can be done suprapubically.
54
If gross blood (\>10mls) is not aspirated or GI contents are not aspirated what is the next step?
Perform lavage with 1L of warmed isotonic crystalloid solution. (10ml/kg in a child)
55
In DPL, when is it considered to be a positive test?
1. \>100,000 red blood cells/mm3
2. 500 WBC/mm3
3. Gram stain with bacteria present.
56
When would you perform a urethrogram?
Before inserting a catheter when a urethral injury is suspected.
57
How is the urethrogram performed?
An **8 French urinary catheter is secured in the meatal fossa** by **balloon inflation to 1.5 to 2mL**. **30 to 35 mL of undiluted contrast** is **instilled** with gentle pressure. Radiographs are then taken.
58
What diagnostic tool is best used to diagnose an intraperitoneal or extraperitoneal bladder rupture?
Cystogram (XR) or CT cystogram.
59
How is a cystogram performed?
A s**yringe barrel is attached to the indwelling bladder catheter**, held **40cm above the patient.** **350mL of water-soluble contrast is allowed to flow** i**nto the bladder until either flow stops**, the **patient voids** or the **patient** is in **discomfort**. **Contrast** is then **instilled** into the bladder.AP and Post drainage images are taken. (XR)
60
What study is most useful if there are urinary system injuries?
A contrast-enhanced CT scan.
NOTE: If CT not available then an IVP (Intravenous pyelogram) is available.
61
On an Intravenous Pyelogram (IVP) what does a **unilateral nonfunction** indicate?
1. Absent kidney
2. Thrombosis
3. Avulsion of the renal artery
4. Massive parenchymal disruption.
62
If a non-function is seen on IVP what further ix is warranted?
Contrast-enhanced CT, renal arteriogram or surgical exploration.
63
What are some advantages & disadvantages of DPL?
Indication: Penetratinga nd blunt trauma
Advantages
* Early diagnosis
* Performed rapidly
* 98% sensitive
* Detects bowel injury
Diadvantages
* Invasive
* Low specificity
* Misses injuries to diaphragm and retroperitoneum
64
What are some advantages & disadvantages of Fast Scan?
Indication: Unstable blunt trauma
Advantages
* Early diagnosis
* Noninvasive
* Performed rapidly
* Repeatable
* 86-97% sensitive
Disadvantages
* Operator dependent
* Bowel gas or subcutaneous air distortion
* Misses diaphragm, bowel or pancreatic injuries.
65
What are some advantages & disadvantages of CT scan?
Indication: **STABLE **blunt trauma and penetrating back/flank trauma.
Advantages:
* Most specific for injury
* 92-98% sensitive
* Non-invasive
Disadvantages
* Cost and time
* Misses diaphragm, bowel and some pancreatic injuries
* Transport required.
66
What percentage of gunshot wounds to the abdomen have intraperitoneal injury? What does this mean for management?
98%. Therefore gunshot wounds are always managed with an exploratory laparotomy.
67
What percentage of stab wounds have an intraperitoneal injury?
30%
68
What are the indications for laparotomy in patients with penetrating abdominal wounds?
* Haemodynamically unstable
* Gunshot wound with a transperitoneal trajectory
* Signs of peritoneal irritation
* Signs of fascia penetration.
69
?% of all patients with penetrating stab wounds to the anterior peritoneum have hypotension, ? or evisceration of ? or ?. This required an ?.
55-60%
Peritonitis
Omentum
Small Bowel
Emergency laparotomy
70
In flank and back injuries what kind of investigations is appropriate?
1. **Serial examinations** (as accurate as CT scan)
2. **Double** or **Triple Contrast CT**
3. **DPL** (invasive)
4. **Laparotomy** (invasive)
NOTE: **Early outpatient follow up after 24 hours** is important due to **subtle injuries** that can manifest later. (i.e. **colonic** injuries)
71
What are the following 9 indications for laparotomy?
1. **Blunt abdominal trauma** with **hypotension** wtih a **positive FAST** or clinical **evidence** of **intraperitoneal bleeding**.
2. **Blunt** or **penetrating** abdominal trauma with a **positive DPL**.
3. **Hypotension** with a **penetrating abdominal** wound.
4. **Gunshot wounds** in the **peritoneal** cavity or **retroperitoneum**.
5. **Evisceration**.
6. **Bleeding** from the **stomach**, **rectum** or **genitourinary tract** from penitrating trauma.
7. **Peritonitis**
8. **Free air**, retroperitoneal air or rupture of the hemidiaphragm.
9. **Contrast**-**enhanced CT** that demonstrates **ruptured GI tract**, intraperitoneal **bladder** **injury**, **renal** pedicle **injury** or severe **visceral** **parenchymal injury** after **blunt** or **penetrating** trauma.
72
Which hemidiaphragm is more commonly injured?
**Left**.
Most common injury is 5 to 10cm in length and on the left posterior hemidiaphragm.
73
What Xray finding is seen with a diaphragm injury?
* A raised hemidiaphragm
* "Blurring" of the hemidiaphragm
* hemothorax.
74
In what 2 situations are duodenal rupture classically encountered?
1. Unrestrained drivers involved in frontal-impact motor vehicle collisions.
2. Handlebar injuries.
75
What situation causes pancreatic injuries?
Direct epigastric blows ...
that compress the pancreas against the thoracic column.
76
Is serum amylase always raised after pancreatic injury?
Nope.
77
What imaging should be done if pancreatic injury is suspected and what time period is it most useful in?
Double contrast CT.
Immediately postinjury (Up to 8 hours)
78
When contusions, hematomas or ecchymoses are seen over the back and flanks what should be done?
CT or IVP to investigate for renal/urinary tract injury.
79
What are the indications for further evaluation of the renal/urinary tract?
1. Gross hematuria
2. Microscopic hematuria in patients with
a) penetrating injury
b) an episode of hypotension and blunt abdo trauma
c) associated with intraabdominal injuries and blunt trauma.
80
What percentage of blunt renal injuries can be treated nonoperatively?
95%
81
In what two rare deceleration renal injuries can haematuria be absent?
1. Renal artery thrombosis
2. Renal pedicle disruption
82
What are anterior pubic fractures often associated with?
Urethral injuries.
83
How are urethral injuries classified?
Posterior (above the urogenital diaphragm)
* usually occur in multisystem injuries
* Pelvic fractures.
Anterior (below) the urogenital diaphragm.
* Straddle impacts
84
Describe the **seatbelt sign**?
The appearance of transverse, linear ecchymoses on the abdominal wall.
Indicates a possible intra-abdominal injury.
85
What is a **Chance Fracture**?
A flexion injury to the lumbar spinal cord when lap belts are used.
86
If a patient has a solid organ injury, what is the chance they will have a hollow viscus injury?
\< 5%
87
What sort of pelvic fractures are associated with haemmorhage?
**Sacroiliac/Sacral fracture** where the **_posterior_** **_osseous ligamentous complex_** is disrupted.
The **pelvic ring tears** the **pelvic venous plexus** and can **disrupt** the **internal arterial system**.
88
What sort of accidents can cause pelvic ring injuries?
* Motorcycle accidents
* Pedestrian vehicle collisions
* Direct crush injuries
* Fall from a greater height than 12 feet (3.6 meters)
89
1 in ? patients with pelvic fractures will die.
1 in ? patients with closed pelvic fractures & hypotension will die.
?% of patients with open pelvic fracture will die.
1 in 6
1 in 4
50%
90
What are the types of Pelvic fracture and what are their frequency rates?
1. Lateral compression (60-70%) - lateral force to pelvis. Rarely bleeds.
2. Anterior-posterior compression (open book - sacroiliac dislocation and disruption of posterior osseous ligamentous complex occurs.) (15-20%) Often bleeds. Very dangerous.
3. Vertical shear. (5-15%) Commonly from fall. Force applied from bottom.
91
How are pelvic fractures managed?
1. Early haemorrhage control - using a sheet, pevlic binder around greater trochanters.
2. Fluid resuscitation
3. Surgery
* If intraperitoneal gross blood --\> Laparotomy
* If NO intraperitoneal gross blood --\> Angiography and probably embolization.
